Failure to Follow Physician Orders for Pain Management
Penalty
Summary
The facility failed to ensure effective and appropriate pain management for a resident with multiple diagnoses, including lymphedema and congestive heart failure. The resident had physician's orders for hydrocodone-acetaminophen to be administered based on specific pain levels: one tablet for pain levels 1-5 and two tablets for pain levels 6-10. However, medication administration records showed that the orders were not followed. The resident received one tablet for a pain level of 0, one tablet for a pain level of 6, and two tablets for pain levels of 4 and 5, which did not align with the prescribed protocol. Staff interviews confirmed that the physician's orders were not adhered to, and the nurse did not review the orders after assessing the resident's pain level. These actions resulted in the resident receiving pain medication inconsistently with the physician's instructions, as documented in the medication administration record and confirmed by facility leadership.