Failure to Timely Enter and Implement New Hydromorphone Order
Penalty
Summary
The deficiency involves the facility’s failure to timely enter and implement a new physician order for scheduled pain medication for Resident #1. The resident was an elderly male with diagnoses including dementia, pancreatic cancer, anxiety, hypertension, hypothyroidism, depression, frequent falls, and pain, and had a BIMS score of 3 indicating severe cognitive impairment. On 11/04/2025, a written order was issued to change his Hydromorphone 4 mg/mL from every 6 hours to every 4 hours, with an additional PRN Hydromorphone order. The facility did not input this new every-4-hour order into the system on the day it was received, so the MAR did not reflect the updated dosing schedule. According to progress notes and interviews, Hospice Nurse D delivered the written order on 11/04/2025 and documented that the existing every-6-hour Hydromorphone order was discontinued and replaced with an every-4-hour schedule plus a PRN order. Hospice Nurse D reported that the facility had been administering the PRN Hydromorphone routinely and that the change to every 4 hours was intended to keep the resident more comfortable. She stated that the facility should have implemented the order the same day to avoid any risk of the resident missing the newly scheduled regimen. Review of the MAR showed that the new every-4-hour order was not entered, and the resident continued under the previous standing PRN order, with pain medication still being administered. Interviews with facility staff revealed miscommunication and assumptions regarding responsibility for entering the order. The DON stated that Hospice Nurse D arrived near the end of her shift, attempted to give her the written order, and was directed to speak with LVN A. The DON reported that Hospice Nurse D placed the orders in a box and informed LVN A that the DON was aware of them. LVN A stated that it was her first day working with the resident, that she initially declined to take the order by phone and requested a written order, and that when Hospice Nurse D later attempted to speak with her in person, she directed her to the DON because she was on the phone. LVN A observed the DON and Hospice Nurse D discussing the orders and assumed the DON would handle them. As a result, the new Hydromorphone every-4-hour order was not entered into the system on 11/04/2025, constituting a failure to administer medications according to the physician’s orders during the identified period of non-compliance.
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