Failure to Follow Physician's Orders for Opioid Administration
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
A deficiency was identified when staff failed to follow a physician's order regarding the administration of opioid medications for a resident with diagnoses including heart failure and obesity. The physician had directed that the resident's as-needed opioid medication (Percocet 5-325 mg) should not be given at the same time as the routine every 12-hour opioid medication (Oxycontin 15 mg ER), and that there should be at least one hour between the two medications. However, review of the Medication Administration Record (MAR) showed that both medications were administered simultaneously at 2100 on September 21, 2025, contrary to the physician's instructions.