The Physical Medicine and Rehabilitation Nurse Practitioner, identified as Staff #15, admitted during a state inspection that he "shouldn't have put Resident #4's oxycodone order for 21 days and that was an error."
Resident #4 was admitted to the facility with a diagnosis of chronic pain due to trauma. The resident's initial physician orders included oxycodone 15 mg every four hours as needed for pain.
Staff #15 managed the resident's pain medication regimen, progressively reducing the dosage over time. He decreased the oxycodone to 10 mg every four hours, then to 5 mg every six hours for a 21-day period.
The medication automatically discontinued when the 21-day order expired. Records show the resident had not taken the as-needed oxycodone since the expiration date.
Staff #15 documented his realization of the problem in a progress note: "Patient not currently on services and is only being seen for pain management. Currently taking Morphine ER 15 mg 2 times a day. His/her as needed oxycodone was discontinued for unknown reasons."
The note continued: "Patient states today that he/she is in pain in his/her lower extremities and that the as needed medication helped control this pain which he/she is no longer receiving."
The resident's complaint to the Office of Health Care Quality triggered the state inspection. During the investigation, Staff #15 acknowledged he should have ordered the oxycodone indefinitely until he could reevaluate the resident.
The Director of Nursing confirmed during an interview that Staff #15 had failed to review the resident's medication orders when the prescription expired.
By the time of the inspection, the facility had reordered oxycodone 5 mg every eight hours as needed for pain. When inspectors interviewed the resident, they reported their pain was under control and they had no issues with their current medication regimen.
The resident told inspectors they could not remember the period when their oxycodone was discontinued or filing the complaint with state health officials.
State inspectors determined this represented a failure to ensure the resident's medical provider properly reviewed care and medication orders. The violation affected one resident and was classified as causing minimal harm or potential for actual harm.
The inspection found that Staff #15's ordering error left a chronic pain patient without access to medication that had previously helped control their lower extremity pain. The gap in medication occurred despite the resident being followed specifically for pain management services.
Federal regulations require medical providers to review residents' care and write appropriate orders during required visits. The inspection revealed this systematic review failed when the 21-day oxycodone order expired without renewal or evaluation.
The resident continued receiving extended-release morphine 15 mg twice daily throughout the period, but lost access to the as-needed oxycodone that provided additional pain relief for breakthrough symptoms.
Staff #15's progress notes documented the resident's report that the discontinued medication "helped control this pain which he/she is no longer receiving." The notes indicated the resident was experiencing pain in their lower extremities without the additional medication option.
The facility's medication administration records confirmed the gap in oxycodone availability, showing the resident had not received the as-needed pain medication since the order expired.
The inspection occurred as part of a complaint investigation, indicating the resident or their representative had contacted state health officials about the medication discontinuation.
Westminster Rehabilitation and Wellness Center must submit a plan of correction to address the deficiency in medical provider oversight of medication orders. The violation represents a breakdown in the systematic review process designed to ensure residents receive appropriate ongoing care for their medical conditions.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Westminster Rehabilitation and Wellness Center from 2025-08-14 including all violations, facility responses, and corrective action plans.
Additional Resources
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