Failure to Monitor for Sedation with Pregabalin Administration
Penalty
Summary
The facility failed to monitor a resident for signs of overmedication while the resident was prescribed Pregabalin for neuropathic pain. Multiple observations over several days showed the resident lying in bed with eyes closed, suggesting possible sedation. The resident's physician order included parameters to hold Pregabalin if sedation occurred, but there was no documentation on the medication administration record (MAR) indicating that monitoring for sedation was performed or that the medication was held as directed. The resident had a history of arthritis, muscle weakness, polyneuropathy, and acute pulmonary edema, and was assessed as having intact cognition but requiring maximal assistance with activities of daily living. Interviews with nursing staff and the DON confirmed the importance of monitoring for sedation and following physician orders, but also revealed that no documentation of such monitoring was present. The facility's policy required monitoring and documentation of medication side effects, which was not followed in this case.