Failure to Follow Physician Orders for Pain Management
Penalty
Summary
Complete Care at Harston Hall LLC was found to be non-compliant with the requirements of 42 CFR Part 483, Subpart B, specifically regarding the quality of care provided to residents. The facility failed to adhere to physician orders for a resident admitted for hospice care. The resident had specific orders for Morphine Sulfate to be administered based on their pain level, with different dosages prescribed for moderate and severe pain. However, the facility administered the medication outside the prescribed parameters, including giving a dose for a pain level that was not indicated in the physician's order and failing to document the pain level for certain administrations. The deficiency was identified through a review of clinical records, staff interviews, and facility policy. It was noted that the resident received Morphine Sulfate for a pain level of 3, which was not within the prescribed range for the medication. Additionally, there were instances where the pain level was not documented at all, which is a requirement for administering the medication as per the physician's order. Interviews with facility staff, including the Unit Manager and the Infection Control and Training nurse, confirmed these discrepancies, and the facility administrator acknowledged the failure to follow physician orders accurately.
Plan Of Correction
1. Resident CL1, Expired at facility on January 8, 2025, on Hospice services. 2. All residents within the facility on Pain management orders will be audited 2 times a week X 4 weeks, then weekly X 4 weeks by the DON/Designee, to ensure pain medications are administered with the correct dosage within the prescribed pain level parameters. 3. All Licensed Nurses will be reeducated on pain level, pain medication administration, and documentation within the appropriate pain level parameters. 4. All results will be brought to the QA committee for review and follow up as needed.