Failure to Follow Physician-Ordered Pain Medication Parameters
Penalty
Summary
Nursing staff failed to administer pain medication according to physician-ordered parameters for one resident with severe cognitive impairment and multiple diagnoses, including dementia, anxiety, and a history of falls. The resident had physician orders specifying the use of acetaminophen for mild to moderate pain (pain scale 1-6) and tramadol for severe pain (pain scale 7-10). Despite these clear orders, the medication administration records showed that the resident was given tramadol for pain levels of 5 and 6 on multiple occasions, when acetaminophen should have been administered according to the orders. Interviews with nursing staff and review of the electronic medical record confirmed that tramadol was not administered in accordance with the physician's specified pain parameters. The DON and corporate nurse consultant acknowledged the discrepancy after reviewing the records. The facility's pain management policy required the use of appropriate pain assessment tools and collaboration with the interdisciplinary team to develop and implement individualized pain management interventions, but these standards were not followed in this case.