Failure to Accurately Document and Administer Ordered Pain Medication
Penalty
Summary
A deficiency occurred when a resident with a history of left below-knee amputation, peripheral vascular disease, type 2 diabetes with hyperglycemia, and cellulitis of the right lower limb did not have complete and accurate documentation of medication administration. The resident had a physician's order for Acetaminophen-Codeine Tablet 300-30 mg to be given every six hours as needed for pain, but missed three doses over two days. The Medication Administration Record (MAR) did not accurately reflect the administration of the ordered medication, and the resident reported receiving a different medication than what was prescribed. The resident reported experiencing significant pain and requested his usual pain medication, but was given Tylenol 500 mg instead of the ordered Acetaminophen-Codeine. The nurse administering the medication confirmed she provided Tylenol 500 mg because the prescribed medication was not available, and she did not inform anyone about the shortage or document the administration of Tylenol 500 mg in the MAR. The nurse also mistakenly signed off in the MAR as if the resident had received the Acetaminophen-Codeine, and failed to add the Tylenol 500 mg order to the electronic medical record. Interviews with facility staff revealed that the nurse did not access the emergency medication supply system or notify supervisors about the unavailability of the prescribed medication. The Director of Nursing and the administrator were not aware of the incident until the resident filed a grievance. The facility's policy required medications to be administered as ordered and documented accurately, but this was not followed in this case, resulting in incomplete and inaccurate medical records for the resident.