Failure to Administer Pain Medications per Physician Orders
Penalty
Summary
A deficiency was identified when a resident, recently readmitted with diagnoses including spinal fusion and orthopedic aftercare, did not receive prescribed pain management medications according to physician orders. The resident was ordered to receive a Buprenorphine patch on a specific date, but the medication was not available in the facility at the time, and a nurse signed off on the administration despite it not being given. This was confirmed through staff interviews and record reviews, which showed the patch was not applied as ordered. Additionally, the same resident was prescribed Dilaudid 4 mg by mouth every six hours as needed for pain, but records revealed that only 2 mg doses were administered on two occasions, contrary to the physician's order. Staff interviews confirmed that the lower dose was given, and the Medication Administration Record inaccurately reflected the administration of the full prescribed dose. The Director of Nursing acknowledged that the resident did not receive the medications as ordered.