Failure to Administer Pain Medication per Physician Orders
Penalty
Summary
The facility failed to ensure that pain medication was administered according to physician orders for a resident with multiple diagnoses, including cellulitis of both lower limbs, muscle weakness, and acute and chronic respiratory failure with hypoxia. The resident had physician orders specifying Tylenol for mild pain rated 1-3/10 and Hydrocodone-Acetaminophen for severe pain rated 7-10/10, but there was no order for pain rated 4-6/10. Despite this, the Medication Administration Record (MAR) showed that Hydrocodone-Acetaminophen was administered for a pain rating of 4/10 on several occasions. Interviews with nursing staff and the Director of Nursing confirmed that the medication was not administered as per the physician's orders and that there was a lack of physician orders for pain rated 4-6/10. Staff did not contact the physician for clarification or new orders when the resident reported pain in this range, as required by facility policy. The facility's policy stated that medications should be administered safely, timely, and as prescribed, but this was not followed in the case of this resident.