Failure to Administer and Accurately Document Scheduled Pain Medication
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to administer a prescribed dose of oxycodone-acetaminophen 7.5-325 mg to a resident at the scheduled time, as ordered by the physician. The resident, who had been admitted with diagnoses including type two diabetes mellitus, a cervical vertebra fracture, and a scalp abrasion, was alert, oriented, and able to communicate needs. The physician's order specified that the pain medication should be given three times daily for pain management. Despite the order, the medication was not administered to the resident on the morning in question. The Medication Administration Record (MAR) incorrectly indicated that the dose had been given, as the LVN documented administration without actually providing the medication. This was later confirmed through interviews and a review of the resident's medication bubble pack and controlled drug record, both of which showed that the medication remained untouched and the count was intact. The resident later reported not receiving any pain medication other than Tylenol, which was ineffective for his pain, and subsequently left the facility against medical advice. The LVN acknowledged the documentation error, stating it was made in haste and that the medication had not been administered. The facility's policy required accurate and timely documentation of medication administration, which was not followed in this instance.