Deficiency #1
Rule/Regulation Violated:
R9-10-120.F.4.a-c. Opioid Prescribing and Treatment <br> F. For a health care institution where opioids are administered as part of treatment or where a patient is provided assistance in the self-administration of medication for a prescribed opioid, including a health care institution in which an opioid may be prescribed or ordered as part of treatment, a medical director, a manager as defined in R9-10-801, or a provider, as applicable to the health care institution, shall: <br> 4. Except as provided in subsection (H), ensure that an individual authorized by policies and procedures to administer an opioid in treating a patient or to provide assistance in the self-administration of medication for a prescribed opioid: <br> a. Before administering an opioid or providing assistance in the self-administration of medication for a prescribed opioid in compliance with an order as part of the treatment for a patient, identifies the patient's need for the opioid; <br> b. Monitors the patient's response to the opioid; and <br> c. Documents in the patient's medical record: <br> i. An identification of the patient ' s need for the opioid before the opioid was administered or assistance in the self-administration of medication for a prescribed opioid was provided, and <br> ii. The effect of the opioid administered or for which assistance in the self-administration of medication for a prescribed opioid was provided.
Evidence/Findings:
<p>Based on documentation review, record review, and interview, the manager failed to ensure an individual authorized to administer opioids documented in the resident's medical record an identification of the resident's need for the opioid before the opioid was administered and the effect of the opioid administered or for which assistance in the self-administration of medication for a prescribed opioid was provided for one of nine residents sampled.</p><p><br></p><p>Findings include: </p><p><br></p><p>1. A review of facility documentation revealed a opioid policy last revised December 13, 2024. The policy stated "Employees will periodically check on the resident over the next hour and note on the MAR (by means of the EMAR follow up feature) the resident’s response to the medication”.</p><p><br></p><p>2. A review of R8's medical record revealed a service plan for personal care services and received medication administration. A review of R8's medication orders dated June 25, 2025 stated, “Oxycodone HCL 5 MG Tablet, take 1 tablet by G-tube twice daily”. A review of R8's medication administration record (MAR) revealed Oxycodone was administered as ordered between September 1, 2025 and September 23, 2025, however, documentation of monitoring of the effect of the opioid was not available for review.</p><p><br></p><p>3. In an exit interview, the findings were reviewed with E1, E2, E3, and E4. E4 reported the facility only tracks the effectiveness of “as needed” medications.</p>
Temporary Solution:
A follow-up prompt was added in the electronic Medication Administration Record for all scheduled opioid medications to occur one hour after administration, in accordance with facility policy.
Permanent Solution:
The post-administration follow-up procedure has been fully implemented and continues to be effective across the facility. All staff authorized to administer medications are now documenting a resident’s response to scheduled opioid medications following their administration in accordance with facility policy. Ongoing compliance has been verified through direct observation and record audits.
Person Responsible:
Zach Briefer, Manager
Summary:
The following deficiency was found on the on-site compliance inspection conducted on September 23, 2025: