Failure to Follow Ordered PRN Pain Medication Parameters
Penalty
Summary
The deficiency involves the facility’s failure to administer pain medication according to the physician’s ordered parameters for one resident. The resident was admitted with diagnoses including COPD, left knee pain, and shortness of breath, and had documented capacity to understand and make decisions, with intact cognitive skills for daily decisions. Physician orders dated 12/19/2025 specified Percocet 5-325 mg by mouth every four hours as needed for moderate pain rated 4–6/10, and Percocet 10-325 mg by mouth every four hours as needed for severe pain rated 7–10/10. Review of the resident’s MAR for January 2026 showed that on 1/2/2026 at 8:16 p.m., LVN 1 administered Percocet 10-325 mg when the resident’s documented pain level was four. During a concurrent interview and record review with the Quality Assurance Nurse, it was confirmed that the resident’s pain level at that time was four out of ten and that LVN 1 administered the higher 10-325 mg dose instead of the ordered 5-325 mg dose for that pain level. The QAN stated that LVN 1 should have looked at and followed the physician’s order. In a separate interview, the DON also stated that LVN 1 should have reviewed and followed the physician order and that, based on the pain level of four, the 5 mg dose should have been administered. The facility’s Pain Assessment and Management policy indicated that the medication regimen is to be implemented as ordered, with results documented and communicated as appropriate. The failure to follow the ordered pain medication parameters for this resident constituted the cited deficiency.
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