F0760

D

Medication Administration Errors With Acetaminophen and Oxycodone

Bethesda, Maryland Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in medication administration for one resident when review of the medical record and MARs showed that acetaminophen was given in excess of the ordered maximum daily dose. The physician had ordered acetaminophen 500 mg, two tablets by mouth every 8 hours as needed for moderate pain, with a directive not to exceed 3 g in 24 hours, and a separate order for Tylenol Extra Strength 500 mg, two tablets by mouth three times a day for pain. Review of the March MAR showed that on two dates the resident received both the scheduled three-times-daily acetaminophen and additional PRN acetaminophen, totaling 4,000 mg in 24 hours, which exceeded the 3,000 mg limit specified in the order. During interview, facility staff reviewed the MAR with the surveyor and acknowledged that the resident received more than 3 g of acetaminophen on those dates.

Further review of the same resident’s record showed physician orders for oxycodone 5 mg by mouth every 6 hours as needed for mild to moderate pain, and oxycodone 7.5 mg by mouth every 6 hours as needed for severe pain rated 7 to 10. The March MAR documented that on one date the resident received oxycodone 5 mg at 7:47 a.m. for pain level 5 and then oxycodone 7.5 mg at 9:37 a.m. for pain level 4, which was before the 6‑hour interval had elapsed. Additional MAR review showed that the resident received oxycodone 7.5 mg on multiple dates for pain levels of 3, 4, and 6, which did not meet the order requirement that this dose be used only for severe pain rated 7 to 10. In interviews, staff confirmed that the 7.5 mg oxycodone was administered both before the 6‑hour interval and for pain levels outside the ordered severity range, and that these administrations were in error.