Failure to Follow Physician Orders for Pain Management
Penalty
Summary
The facility failed to provide pain management according to the physician's orders and the resident's care plan for one resident. The resident had orders for pain to be monitored every shift and for specific pain medications to be administered based on the pain scale: Percocet for severe pain (level 7-10) and Hydrocodone for moderate to severe pain as needed. However, a review of the Medication Administration Record (MAR) showed that Hydrocodone was administered for pain levels of 7 and above multiple times, which did not align with the physician's order specifying Percocet for those pain levels. The resident was receiving PRN pain medications multiple times daily without the pain scale being matched to the correct medication as ordered. Interviews with the resident confirmed frequent administration of pain medications, and the DON acknowledged that the physician's orders were not being followed as written. The facility's own pain management policy required appropriate assessment and treatment of pain, including reviewing the MAR to determine the frequency and effectiveness of PRN pain medication use. Despite these procedures, the staff did not ensure that pain medications were administered according to the prescribed pain scale, nor did they contact the physician to adjust the medication regimen when frequent PRN use was observed.