Failure to Administer Pain Medication as Ordered
Penalty
Summary
A deficiency occurred when the facility failed to provide services according to physician orders for a resident with chronic pain syndrome, arthritis, osteoporosis, and fibromyalgia. The resident's care plan required staff to anticipate and respond to pain, evaluate the effectiveness of pain interventions, and monitor for non-verbal signs of pain. Despite these directives, clinical record review showed that the resident's prescribed Diclofenac Sodium Gel was not administered as ordered on multiple occasions during the evening medication pass over a period of more than a month. The Medication Administration Record and Treatment Administration Record documented numerous missed doses, and the resident reported that her medications were often late and her pain cream was missed on some days. She had communicated these concerns to nursing staff, the DON, and the Administrator. Interviews with LPNs confirmed that medications had been missed or given outside the scheduled time range. One LPN also reported that the resident had expressed concerns about missed medications and other care issues, and noted that staffing levels were insufficient for the care needs of residents. Facility policy required medications to be administered by licensed nurses as ordered by the physician and within 60 minutes of scheduled times, but this standard was not met for the resident in question.