Failure to Administer Pain Medication According to Physician's Order
Penalty
Summary
The facility failed to provide adequate and appropriate pain management for a resident who required such services. Specifically, a physician's order directed that tramadol HCL 50 mg be administered by mouth every six hours as needed for severe pain rated 7-10 on a 0-10 pain scale. However, medical record review showed that the medication was administered when the resident's pain level was documented as six, which did not meet the criteria specified in the physician's order. This discrepancy was verified by the Assistant Director of Nursing (ADON) during an interview and concurrent record review, and was acknowledged by the Director of Nursing (DON) upon review of the findings. The failure to follow the physician's order for pain medication administration resulted in the resident receiving tramadol HCL outside the prescribed pain level parameters.