Failure to Administer Pain Medication According to Physician Orders
Penalty
Summary
A deficiency occurred when a resident with multiple left-sided rib fractures and high blood pressure, who was cognitively intact and able to make decisions, did not receive pain medication in accordance with physician orders. The resident had an active order for Dilaudid 1 mg by mouth every four hours as needed for moderate pain (pain scale 4-6). During a medication administration observation, a nurse assessed the resident's pain at a level of seven, which is categorized as severe pain, but still administered Dilaudid as ordered for moderate pain. The nurse stated that pain medication for severe pain was unavailable and planned to reassess and contact the physician for further orders. The facility's care plan indicated that Dilaudid should be administered as ordered by the physician, and facility policy required medications to be given in accordance with prescriber orders. The DON confirmed that the physician should have been notified to obtain appropriate orders for severe pain and acknowledged that the ordered parameters were not followed. Facility policy also defined a medication error as administering drugs not in accordance with physician orders or accepted professional standards.