Failure to Administer PRN Pain Medication as Ordered
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses including rheumatoid arthritis, osteoarthritis, and osteopenia did not receive pain medication as ordered by the physician. The resident's care plan specified the need for pain management, including administration of hydrocodone-acetaminophen 7.5-325 mg every 4 hours as needed for pain. Despite this order, the resident reported requesting her pain medication at 6:00 AM, but did not receive it until more than 2.5 hours later. During this time, the resident experienced significant pain, rating it as a 7 out of 10, and was observed to be tearful and in distress. Staff initially believed the medication was scheduled every 12 hours, not every 4 hours as needed, leading to a delay in administration. Interviews with staff confirmed a communication breakdown regarding the correct pain medication order. The resident, who was alert and oriented, consistently reported her pain and her usual pain management routine. Documentation showed that the resident's pain was effectively managed when the medication was administered as ordered, but the delay on this occasion resulted in unnecessary suffering. The facility's pain management policy emphasized the importance of timely and appropriate pain control, which was not followed in this instance.