Failure to Administer Scheduled Pain Medication as Ordered
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including type 2 diabetes mellitus, a cervical vertebra fracture, and a scalp abrasion, was not administered his scheduled pain medication as ordered by his physician. The physician's order specified that the resident should receive oxycodone-acetaminophen 7.5-325 mg orally three times a day for pain management. Review of the Medication Administration Record (MAR) indicated that a Licensed Vocational Nurse (LVN) documented administration of the medication on the morning following admission. However, further investigation revealed that the medication was not actually given. The resident's medication bubble pack remained intact with all 30 tablets present, and the controlled drug record confirmed that none of the prescribed doses had been dispensed. The LVN responsible for the resident's care admitted during an interview that she did not administer the medication and had mistakenly documented its administration in the MAR while in a rush. The resident later reported that he did not receive his prescribed pain medication and was only offered Tylenol, which he stated was ineffective for his pain. Facility leadership confirmed that the medication was not administered as ordered and that the documentation in the MAR was inaccurate. The facility's pain management policy required daily assessment and documentation of pain interventions, but in this instance, the resident did not receive the scheduled pain medication, and the documentation did not reflect the actual care provided.