Failure to Honor Resident Preference for Whole Opioid Tablets
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to be treated with dignity and to have preferences respected regarding medication administration. Resident #3, admitted with osteomyelitis of the vertebra, PTSD, and opioid dependence, had intact cognition (BIMS score of 15), ate independently, and had no issues with holding food in the mouth. Provider orders initially directed Hydromorphone tablets to be given whole by mouth as needed for pain. In early December, amid concerns about inappropriate use of controlled substances by other residents, the APRN issued a new order that all narcotic medications for this resident be crushed and administered in applesauce or pudding. This change was made without an individualized assessment of Resident #3’s swallowing ability or behavior and without honoring the resident’s stated preference to receive whole tablets. Resident #3 reported that controlled substances were being misused by other residents and that their Hydromorphone order was changed from whole to crushed tablets by the APRN to avoid misuse of the tablets. The APRN confirmed that any resident with an order for Hydromorphone and a diagnosis of opioid use disorder had their orders changed from whole tablets to crushed form to prevent pocketing or diversion. The DNS stated that some residents with a history of substance use disorder had controlled substances crushed and that mouth checks were regularly performed, but also acknowledged there was no facility policy for crushed medication practice. The DNS was aware that Resident #3 did not want their Hydromorphone crushed, yet the order remained in place based on the APRN’s discretion, and if the resident refused crushed medication it was documented as refused. This practice conflicted with the facility’s stated Resident Rights, which include the right to be treated with consideration, respect, and full recognition of dignity and individuality.
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