Failure to Document Administration of Pain Medication
Penalty
Summary
A resident with multiple complex medical conditions, including anoxic brain damage, chronic respiratory failure, COPD, Alzheimer's disease, dementia, and bipolar disorder, was admitted to the facility and was under hospice care. The resident was found to have a contusion on the left foot and reported significant pain, which was assessed by a hospice nurse practitioner who ordered an x-ray and subsequently, after the resident's pain was rated at 7 out of 10, a hospice physician ordered oxycodone 5 mg every six hours as needed for pain greater than five. On the day the pain medication was ordered and administered, the nurse retrieved oxycodone from the Ekit and gave it to the resident. However, there was no documentation on the resident's medication administration record (MAR) to indicate that the oxycodone had been administered. During interviews, the DON confirmed that staff are required to document all medications pulled from the Ekit on the MAR, and the nurse involved acknowledged that she administered the medication but forgot to document it.