Failure to Provide Timely and Accurate Pain Management
Penalty
Summary
The facility failed to provide pain management in accordance with a resident's physician orders, resulting in inadequate pain control for a resident who had recently undergone a total hip arthroscopy. Upon admission, the resident's hospital discharge orders specified Oxycodone 2.5-5mg by mouth every three hours as needed. However, the order was incorrectly transcribed in the facility's electronic medical record as only 2.5mg every three hours, omitting the 5mg option. Additionally, there were documented instances where the resident reported pain levels of 7 or higher, but did not receive the prescribed prn Oxycodone, and instead was given Tylenol. When Oxycodone was administered, there was no follow-up documentation regarding its effectiveness. A delay in receiving Oxycodone from the pharmacy occurred due to an allergy alert related to the resident's documented Hydrocodone allergy, but there was no evidence that the provider was notified of the delay or that alternative orders were requested. The facility's investigation did not identify the transcription error, and the administrator was unaware of the error or the lack of response regarding medication availability. The resident expressed dissatisfaction with pain management, noting delays in receiving medication and inadequate pain relief, which contributed to their decision to discharge against medical advice.