Failure to Follow Up on Pain Management for Resident with Medication Allergies
Penalty
Summary
The facility failed to provide appropriate pain management for a resident who was allergic to both Aspirin and Acetaminophen. Upon admission, the resident's records clearly indicated these allergies. Despite this, a Pain Management Doctor ordered Tylenol (Acetaminophen) for pain, which was not administered due to the known allergy. The nurse documented that the PMD was notified about the allergy, but there was no follow-up for three days to obtain an alternative pain medication. Facility policy required staff to follow up with the physician three times within 24 hours and, if no response was received, to contact the resident's primary doctor or the Medical Director. Interviews with staff confirmed that the required follow-up actions were not taken, and the resident's pain management needs were not addressed in a timely manner. The resident's family member reported that the resident experienced stomach pain and was told by the PMD that pain medication would be ordered if needed. The lack of follow-up resulted in the resident potentially experiencing untreated pain, as no alternative pain management was provided during the period in question.