Failure to Provide Safe and Effective Pain Management
Penalty
Summary
The facility failed to provide effective pain management and monitoring for a resident, resulting in the administration of more medication than prescribed. Staff interviews and record reviews revealed that the narcotics log book did not accurately reflect the number of fentanyl patches administered, and there was a lack of clear documentation regarding the application, removal, and effectiveness of the patches. Staff members were not fully trained on the facility's medication management process, and one staff member admitted to following procedures from previous employment rather than facility-specific protocols. Additionally, there was no documentation to ensure that the fentanyl patches were in place for the correct duration, nor was there evidence of monitoring for adverse reactions or effectiveness. The resident experienced unmanaged pain, leading to multiple changes in pain medication, including the discontinuation of Norco, initiation of fentanyl patches, and subsequent switches between different dosages and types of pain medications. The medication administration record showed that acetaminophen was given in excess of the prescribed daily limit on one occasion. Progress notes indicated the resident became increasingly lethargic, unarousable, and cold to the touch, ultimately requiring transfer to the emergency room, where a reaction to medication was suspected. The lack of consistent monitoring and documentation contributed to the resident receiving more medication than prescribed and experiencing adverse effects.