Opioid PRN Order Not Followed for Pain-Level Parameters
Penalty
Summary
The facility failed to ensure a resident’s opioid pain medication was used only with adequate indications, as required by its Unnecessary Drugs policy, which states that a resident’s medication regimen must be free from unnecessary drugs, including those given without adequate indications for use. A resident with multiple diagnoses, including a right above-knee amputation and diabetes, had PRN orders for acetaminophen 325 mg every 4 hours as needed for pain rated 1–5, and Percocet 10-325 mg every 4 hours as needed, with a maximum of 4 doses per day, for pain rated 6–10. Medication administration records showed that Percocet was repeatedly administered for pain levels documented as 4 or 5, which did not meet the ordered indication of pain rated 6–10. On interview, the DON confirmed that the pain medication should have been administered according to the ordered pain levels and that it had not been, demonstrating that the resident’s opioid regimen was not managed in accordance with the facility’s policy and the physician’s orders. This failure was identified for one of seventeen residents reviewed for unnecessary medications and created the potential for residents to experience adverse consequences or increased risk of death.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.