Failure to Document and Manage PRN Pain and Narcotic Medications per Professional Standards
Penalty
Summary
The facility failed to ensure that nursing services met professional standards of quality for a male resident admitted after an open reduction and internal fixation (ORIF) procedure, with a history including lumbosacral and pelvic fractures, motor vehicle accident, anemia, anxiety disorder, and psychoactive substance abuse. The resident reported that his pain was not being controlled and that staff told him there was no oxycodone order, despite an active physician order for oxycodone 10 mg every 4 hours PRN for pain and acetaminophen 325 mg, three tablets every 6 hours PRN for pain. Review of the Medication Administration Record (MAR) for January showed no documentation that oxycodone or acetaminophen had been administered from admission through the end of the month, even though pharmacy records showed delivery of oxycodone tablets. The narcotic receipt and disposition form for January could not be located. In February, oxycodone was documented as given only about five times, acetaminophen was not signed out at all, and additional oxycodone deliveries were documented by the pharmacy. There was no documentation in the record of medication refusals, PRN indications, or effectiveness assessments as required by the facility’s medication administration guidelines. The facility also failed to ensure appropriate assessment and documentation of the resident’s pain and surgical site. The record lacked documentation of the effectiveness of administered pain medications, any non-pharmacological pain interventions, or assessments of the resident’s surgical site each shift by floor nurses. An RN stated that the resident’s surgery was healed and that wound care was responsible for the surgical site, and she was not aware of the presence of staples or swelling at the right hip, indicating she had not assessed the site. These practices were inconsistent with the facility’s policies and the RN/LPN job descriptions, which require accurate charting, signing and dating all entries, complete MAR documentation for PRN medications (including results), and ensuring narcotic records are accurate for each shift.
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