Failure to Administer Ordered Pain Medication Dose Resulting in Uncontrolled Pain and Hospital Transfer
Penalty
Summary
A resident with diagnoses including sciatica and a progressive neurological disorder was admitted to the facility and had a care plan that included pain medication therapy. The resident had physician orders for Tramadol 50 mg every six hours as needed and 100 mg scheduled at bedtime. On the evening in question, the resident received only 50 mg of Tramadol at bedtime instead of the ordered 100 mg. The resident continued to experience severe pain, rating it as a 10 out of 10, and was subsequently given Tylenol, which did not alleviate the pain. The nurse did not administer the additional 50 mg of Tramadol, stating there was no order for more, despite the resident's request and clarification that only half the ordered dose had been given. As a result of the inadequate pain management, the resident's pain remained uncontrolled, leading to a transfer to the hospital emergency room, where the resident continued to report intense pain. The facility's review of emergency room transfers revealed the medication error. The Director of Nursing confirmed that the resident had an order for 100 mg of Tramadol at bedtime but only received 50 mg, resulting in harm due to uncontrolled pain.