Failure to Follow PRN Pain Medication Orders Based on Pain Scale
Penalty
Summary
The facility failed to follow a physician’s order for as-needed (PRN) pain medication for one resident when nursing staff administered Oxycodone 5 mg for pain levels documented as zero. Facility policy titled “Pain Observation/Evaluation,” revised January 2026, defined the 0–10 pain scale and specified that mild pain corresponds to 0–3, moderate to 4–7, and severe to 8–10. The resident had a physician’s order for Oxycodone 5 mg to be given every 6 hours as needed for severe pain. Review of the January Medication Administration Record showed that the resident received Oxycodone 5 mg every 6 hours as needed on multiple dates despite pain levels recorded as zero at the time of administration. In an interview, the Nursing Home Administrator and DON confirmed that the pain scale specified in the physician’s PRN pain medication order was not followed according to the order.
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