Failure to Administer Pain Medication Prior to Wound Care
Penalty
Summary
The facility failed to ensure that a resident received care and treatment in accordance with professional standards of practice by not following physician's orders. The resident, who was cognitively impaired, required assistance for daily care, and was receiving hospice care, had specific orders for wound care and pain management. The orders included cleansing and dressing the resident's right foot daily and administering 15 mg of immediate-release morphine 30 minutes prior to wound care. However, the morphine was scheduled for administration at 8:00 a.m., while the wound care was scheduled to occur anytime between 6:00 a.m. and 6:00 p.m., leading to inconsistencies in pain management. On December 11, 2024, it was observed that the resident's wound care was performed at 10:22 a.m. without documented evidence of morphine administration 30 minutes prior, as ordered. An interview with the resident revealed that wound care was completed at varying times each day, depending on staff availability. The Director of Nursing confirmed the lack of documentation for the timely administration of pain medication before wound care, indicating a failure to adhere to the physician's orders.
Plan Of Correction
1. Immediate intervention completed. Medication and treatment time updated to reflect specific times of administration and completion. 2. The Interdisciplinary team will review pain medications with specific times as it relates to treatment/wound care. 3. Pain medications with specific times related to a treatment will be reviewed during morning clinical meeting to determine if the physician needs contacted related to the timing of order. The Director of Nursing/designee will educate licensed nursing staff including agency on pain medication and treatments related to residents with specific times of orders. Will discuss with physician as needed. 4. To maintain and monitor compliance, a weekly audit will be conducted by the Director of Nursing or designee for four weeks then monthly for two months to ensure that physician orders are completed as ordered. Results of this audit will be reviewed by the Quality Assurance and Improvement Committee for additional recommendations if necessary.