Failure to Administer PRN Opioid According to Ordered Pain Levels
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s opioid pain regimen was administered according to the ordered indications for use, as required by the facility’s Pain Management policy. The policy, revised on 12/29/25, stated that pharmacological interventions would follow a systematic approach and that evidence-based practice tools would be considered to assist in assessing analgesic therapy. Resident #23, admitted with osteomyelitis and sepsis, had physician orders for oxycodone 5 mg: one tablet by mouth every 4 hours as needed for moderate pain and two tablets by mouth every 4 hours as needed for severe pain. The facility used a standard pain scale where scores of 1–3 indicated mild pain, 4–6 moderate pain, and 7–10 severe pain. Record review of the MAR showed that the resident received two tablets of oxycodone (the dose ordered for severe pain) on multiple occasions when the documented pain level was in the moderate range (pain scores of 4–6) and once when the pain level was documented as 2, which is in the mild range. These administrations occurred on several dates, with pain scores of 4, 5, or 6 documented at the time of administration, and one instance with a pain score of 2. During an interview, the DNS confirmed that the facility uses the standard pain scale and acknowledged that the pain medication should have been administered according to the ordered pain levels but had not been, indicating the resident was not assessed and treated in alignment with the prescribed indications for opioid use.
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