Failure to Follow Provider Orders for Pain Medication Administration
Penalty
Summary
Nurses at the facility failed to follow provider orders for pain medication administration, as evidenced by medication administration records (MARs) and staff interviews. For three residents with multiple diagnoses including fractures and a history of falls, pain medications were given outside the prescribed pain level ranges. Specifically, one resident received oxycodone for pain levels below the ordered threshold on multiple occasions, while another was given ibuprofen and oxycodone for pain levels not matching the provider's specified range. A third resident was administered oxycodone for pain levels above the ordered range on two consecutive occasions. The Director of Nursing (DON) confirmed that nurses did not follow provider orders and acknowledged that resident preference does not supersede provider orders. These actions were identified through record review and staff interviews, demonstrating a failure to ensure that nursing services met professional standards of quality as required.