Failure to Administer PRN Oxycodone and Maintain Controlled Substance Records
Penalty
Summary
The facility failed to provide effective pain management for a resident with chronic pain, resulting in excessive pain, poor sleep, and decreased ability to perform activities of daily living. The resident had diagnoses including diabetes, heart failure, and depression, and was care planned for chronic pain with an intervention to administer medications per physician orders. A physician order dated 12/23/25 directed staff to administer Oxycodone 5 mg by mouth every eight hours as needed. The resident reported requesting Oxycodone for breakthrough pain and not receiving it on three consecutive days, stating that this caused significantly increased pain, poor sleep, reduced time out of bed, and inability to complete usual activities such as doing laundry. Review of the resident’s Medication Administration Record for the relevant days showed blank entries for the as-needed Oxycodone, indicating it was not administered. Additionally, when the resident’s chart was reviewed, the controlled substance record for Oxycodone was missing, preventing verification of whether any doses had been given. A registered nurse confirmed that the controlled substance record could not be located and that they were unable to identify if the resident had received Oxycodone as requested. The clinical consultant later confirmed that the MAR entries for the three days in question were blank and acknowledged that the facility failed to provide effective pain management, causing harm to the resident, in violation of 28 Pa. Code 211.12(d)(3)(5) Nursing Services.
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