Failure to Administer Prescribed Pain Patch as Ordered
Penalty
Summary
A deficiency occurred when a resident with chronic pain, morbid obesity, and hemiplegia did not receive their prescribed Lidocaine pain patch as ordered. The resident had an active order for a Lidocaine patch to be applied daily to the left knee for pain management, as documented in the care plan and medication administration record. Despite this, the medication administration record showed multiple days where the patch was not administered, and staff interviews confirmed that the patch was often not given, even though it was signed as administered. Observations and interviews revealed that the resident frequently reported significant pain, with pain levels ranging from 4 to 7 out of 10, and expressed that the Lidocaine patch was the only effective intervention. The resident was observed on several occasions without the patch and reported that they had repeatedly requested it from nursing staff, who sometimes offered alternative treatments that were ineffective. Staff interviews indicated confusion about the storage location of the patches, with some nurses believing the patches were in the medication cart when they were actually kept in the treatment cart, leading to missed doses. Nursing staff admitted to signing off on the administration of the Lidocaine patch before actually applying it, resulting in the resident not receiving the medication as ordered. The facility's policies required that medications be administered and documented correctly, but these procedures were not followed. The failure to administer the prescribed pain management as ordered led to the resident experiencing ongoing pain and decreased mobility.