HospitalInspections.org

Based on document reviews and interviews, the facility failed to ensure that oxycodone (a narcotic pain medication) was administered in accordance with the provider's orders for one (1) out of ten (10) patient records reviewed (Patient #4).

Findings:

The facility's policy titled, "Medication Administration," last reviewed 05/29/2024 states in part, "...Medications shall be administered pursuant to a valid order..."

Patient #4's medical record was reviewed on 11/19/2024 with the assistance of Registered Nurse ("RN") #1.

Patient #4's medical record revealed that as of 10/22/2024, Patient #4 had the following orders for oxycodone:

-an order for oxycodone ten (10) milligrams (mg) as needed ("PRN") for a pain score of 7-10

-a separate order for oxycodone five (5) mg PRN for a pain score of 4-6

Patient #4's medical record revealed that on 10/22/2024 at 12:46 PM, Licensed Practical Nurse ("LPN") #1 documented Patient #4 had a pain score of six (6), and administered ten (10) mg of oxycodone - outside of the parameters of the provider's order.

On 11/19/2024 at 11:27 AM, RN #1 confirmed that on LPN #1 had administered the ten (10) mg dose of oxycodone outside of the parameters of the provider's order.