Failure to Administer Oxycodone as Ordered Every 4 Hours
Penalty
Summary
The deficiency involves the facility’s failure to administer pain medication as ordered for a cognitively intact resident with necrotizing fasciitis, major depressive disorder with anxiety, and type 2 diabetes. The resident was admitted with these diagnoses and had an MDS BIMS score of 13/15, indicating intact cognition. During an observation, the resident reported concerns that their pain medications were occasionally administered late. The physician’s order dated 12/30/25 directed that oxycodone 10 mg be given every four hours, and the MAR showed scheduled administration times at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM daily. Review of the controlled substance records for the resident’s oxycodone 10 mg showed multiple instances where the medication was signed out at intervals shorter or longer than the ordered four hours. Examples included doses given approximately 2 hours and 18 minutes apart, 4 hours and 45 minutes apart, 4 hours and 50 minutes apart, over 5 hours apart, and as close as 1 hour and 45 minutes apart on various dates. In an interview, an RN stated that nurses often worked two halls, resulting in late medication administration. The DON stated that the controlled substance records should reflect the time the medication was pulled for administration and that, for an every-4-hour order, staff were expected to sign it out every four hours unless refused. The DON reviewed the records and agreed that the oxycodone had been signed out outside of the ordered every-4-hour schedule.
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