Failure to Administer Ordered Oxycodone Due to Lack of Access to Narcotic Keys
Penalty
Summary
The deficiency involves the facility’s failure to administer pain medication as prescribed and to ensure access to ordered narcotics for a resident with generalized pain. Facility policies required medications to be administered in accordance with prescriber orders and emphasized appropriate assessment and treatment of pain. The resident’s care plan identified generalized pain with an intervention to administer analgesics as ordered, and a physician’s order prescribed oxycodone 5 mg every six hours as needed for pain. The resident had diagnoses including gout and liver cirrhosis and a BIMS score of 12, indicating moderate cognitive impairment. Medication administration records for the reviewed period showed the resident received oxycodone on the day and evening shifts on one date, with documented pain scores of 4/10 and 6/10, but there was no documentation that oxycodone was administered on the overnight shift. A nurse’s note documented that the resident requested oxycodone during the overnight shift and was told there was no primary nurse available to administer narcotics. The resident was offered Tylenol instead, but refused, stating they could not take Tylenol due to their liver condition and reporting that their liver transplant physician had advised against Tylenol. The resident later stated they hurt all over all the time, that they received oxycodone every six hours, and that they had been denied oxycodone due to no available staff. A CMA reported the resident frequently complained of pain and that oxycodone had been ordered as needed until it was changed to a routine every-six-hour schedule. The LPN on duty during the overnight shift stated they were the only nurse on duty, refused to accept the narcotic lockbox keys for the resident’s hall, did not know where those keys were, and therefore did not administer oxycodone when the resident, who rated their pain 10/10, requested it. The DON stated facility policy was to administer medications as ordered and that the resident’s oxycodone should have been given and an alternative to Tylenol should have been available.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.