Failure to Follow Physician-Ordered Medication Parameters
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including fibromyalgia, chronic pain, dementia, and other conditions, was administered Tramadol HCL 50 mg outside of the physician-ordered parameters. The physician's order specified that the medication should only be given for moderate to severe pain levels of 6 to 10. However, review of the Medication Administration Record (MAR) showed that the medication was administered on several occasions for pain levels documented as 4 or 5, which did not meet the criteria set by the physician's order. Interviews with facility staff, including the DON and the Medical Director, confirmed that staff are expected to follow medication orders and parameters as written. An LPN acknowledged administering the medication outside the prescribed parameters. Additionally, when requested, the facility was unable to provide policies and procedures related to medication administration and following physician orders by the time of survey exit.