Failure to Administer Pain Medication per Physician Orders
Penalty
Summary
The facility failed to provide adequate and appropriate pain management for one resident by not administering pain medication according to the physician's orders. The resident had clear physician orders for different pain medications based on the severity of pain, as indicated by a pain scale. Specifically, Tylenol 325 mg was to be given for mild pain, hydrocodone-acetaminophen 5-325 mg for moderate pain, and hydrocodone-acetaminophen 10-325 mg for severe pain. However, medical record review showed that the resident received hydrocodone-acetaminophen 5-325 mg for pain levels of eight, which was outside the prescribed range for that medication, and Tylenol for a pain level of six, which was also not in accordance with the physician's order. Interviews with both an LVN and the DON confirmed that the resident did not receive the correct medication for the reported pain levels and that the physician's orders were not followed. The facility's policy required medications to be administered as prescribed by the attending physician, but this was not adhered to in this case. The resident was documented as having the capacity to understand and make decisions, and the failure to follow the medication orders was verified through both medical record review and staff interviews.