PRN Oxycodone Administered Outside Ordered Pain Parameters
Penalty
Summary
Facility staff failed to ensure that a resident’s pain medication was administered according to the physician’s order, resulting in multiple doses of Oxycodone being given outside the prescribed parameters. The physician’s order dated 2/4/26 specified Oxycodone 15 mg by mouth every 4 hours as needed for pain rated 5–10 on a 1–10 scale. Review of the Medication Administration Record showed that on 2/6/26 at 8:25 PM; 2/10/26 at 10:37 AM and 5:55 PM; 2/11/26 at 1:50 AM; 2/13/26 at 9:17 PM; 2/14/26 at 1:30 AM and 6:05 AM; and 2/15/26 at 4:33 PM and 8:55 PM, the resident’s pain level was documented as 4, yet the Oxycodone was administered. These administrations did not comply with the physician’s order limiting use of the medication to higher pain scores. During an interview, the DON was informed of these findings and acknowledged that the medication should not have been administered under those circumstances.
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