Failure to Administer and Document Pain Medication per Physician Orders
Penalty
Summary
A resident with dementia, cervical spine fusion, and a right humerus fracture was admitted to the facility and placed on pain medication therapy for chronic pain syndrome. The care plan required administration of analgesic medications as ordered by the physician and monitoring for side effects and effectiveness. A physician's order specified Dilaudid (Hydro-morphine HCI) 2 mg oral tablets, with 0.5 mg to be given every 4 hours as needed for pain. Review of the narcotic count sheet showed that an LPN logged out doses on multiple occasions, but the Medication Administration Record (MAR) did not reflect administration of the medication on several dates when the narcotic count sheet indicated it had been dispensed. Further review revealed that the resident complained of pain, and the nurse on duty was unable to administer pain medication due to discrepancies in the narcotic count sheet and medication cart key handoff times. Staff interviews indicated that the LPN may have either failed to document administration on the MAR or possibly diverted the medication, as it was not reasonable for documentation to occur on the narcotic count sheet but not on the MAR multiple times in a short period. Facility policy required medications to be administered and documented per physician orders, and defined misappropriation to include missing or diverted prescription medications.