Administration of Controlled Medications Without Valid Physician Order
Penalty
Summary
Facility staff failed to comply with state regulations by administering tramadol and oxycodone to a resident without a valid physician's order. The resident had previously been prescribed these medications, but the orders were discontinued upon the resident's return from a hospital stay. Despite the absence of current orders in the system, a registered nurse administered both medications on the same day, relying on the presence of medication cards in the medication cart and assuming the medications were still prescribed. The nurse did not directly consult with the resident's physician before administering the drugs. Subsequently, the nurse entered backdated orders into the electronic system several days after the medications were given, based on information from nursing management that the physician had approved the orders. However, the physician later stated he did not recall being asked or approving the administration of these medications. Interviews with other staff members, including the staff development coordinator and the director of nursing, revealed a lack of direct involvement or recollection regarding the late entry of orders. The executive director was informed of the issue, and no further information was provided before the survey exit.