Failure to Administer Prescribed Pain Medication as Ordered
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including heart failure, chronic obstructive pulmonary disease, a history of myocardial infarction, and a fractured thoracic vertebra, did not receive prescribed pain medication as ordered by the physician. The resident was on a scheduled pain medication regimen, including Percocet three times daily for chronic pain and as-needed oxycodone. On two separate occasions, the resident did not receive the scheduled Percocet, as documented in the medication administration record. Progress notes and administration records indicated that the Percocet was not available and was not administered, despite the resident experiencing significant pain, with pain scores reported as high as 8 out of 10. The resident expressed dissatisfaction with pain management and reported that the medication changes were not effective. There was no documentation that the physician was notified about the unavailability of the prescribed medication or the ineffectiveness of the alternative pain management provided. Interviews with the DON confirmed that the nurse should have notified the physician when the medication was not available and that alternative sources, such as the emergency kit, could have been used. However, these actions were not taken, and the resident's pain was not effectively managed according to the physician's orders, resulting in a significant medication error.