Unnecessary Medication Administration Without Physician Order
Penalty
Summary
Facility staff failed to ensure that a resident was free from unnecessary medications by administering tramadol and oxycodone without a current physician's order. After the resident returned from a hospital stay, the previous orders for these medications were discontinued. Despite this, a registered nurse administered both tramadol and oxycodone to the resident on a specific date, relying on the presence of medication cards in the medication cart rather than verifying active orders in the computer system or on the medication administration record (MAR). A review of the clinical record and MAR confirmed that there were no active orders for these medications at the time they were given, and the orders were only backdated in the system several days later. The nurse involved acknowledged during an interview that she made an error by not confirming the existence of current physician orders before administering the medications. Facility policy requires that medications be administered only as ordered by a physician, and that staff review the MAR to identify medications to be administered.