Failure to Clarify Pain Medication Orders for a Resident
Penalty
Summary
The facility failed to ensure that pain medication orders for a resident with chronic back and leg pain were properly clarified with the physician regarding the appropriate pain level parameters for each medication. The resident, who had a history of multiple spinal surgeries and was diagnosed with spondylolisthesis and other musculoskeletal conditions, was observed to be alert and oriented while reporting ongoing pain. A review of the resident's Medication Administration Record revealed that both Tylenol and Hydrocodone-acetaminophen were ordered for the same pain level range (4-6), which could cause confusion for nursing staff regarding which medication to administer. A licensed nurse confirmed that the identical pain level parameters for both medications could lead to uncertainty in pain management. The Director of Nursing acknowledged that the orders were written in error and, without clarification from the physician, there was potential for the resident to receive duplicate medications. The facility's policy requires contacting the physician in the event of medication discrepancies, but this was not done in this case.