Failure to Administer Pain Medication According to Physician Orders
Penalty
Summary
The facility failed to manage a resident's pain in accordance with its own Pain Assessment and Management policy and the physician's orders. The resident, who was admitted with diagnoses including osteoarthritis of the left hip, anemia, and essential hypertension, had physician orders specifying acetaminophen 650 mg every four hours as needed for mild pain (pain scale 1-3) and ibuprofen 400 mg every six hours as needed for moderate pain (pain scale 4-6). The resident's care plan indicated a risk for pain and directed staff to administer medications as ordered. However, review of the Medication Administration Record (MAR) and interviews with nursing staff revealed that the resident repeatedly received ibuprofen 400 mg for mild pain episodes (pain scale 2-3), instead of the ordered acetaminophen for that pain level. Nursing staff, including a registered nurse and the Director of Nursing, confirmed that the resident was given pain medication not appropriate for the assessed pain level and not in accordance with the physician's orders. The facility's policies required medications to be administered as prescribed, but these were not followed, resulting in the resident receiving ibuprofen for mild pain on multiple occasions. This failure was identified through record review and staff interviews, and it was acknowledged that the resident's pain may not have been managed as intended by the care plan and physician orders.