Failure to Administer and Document Pain Medications as Ordered
Penalty
Summary
The facility failed to ensure that staff administered ordered pain medications to residents according to their needs and as outlined in their care plans, and also failed to ensure that residents' medications were readily available. Two residents with significant pain management needs were affected, resulting in multiple missed doses of approximately nine different pain medications. These failures were identified through observation, interviews, and record reviews, and had the potential to affect all residents on the first floor. One resident with diagnoses including malignant neoplasm of bone, osteomyelitis, and a lumbar vertebrae fracture reported unmanaged pain due to inconsistent administration of pain medications. The resident stated that staff frequently told him he was not due for his medication and that alternative pain relief was not provided. Medication administration records showed that several pain medications, including lidocaine patches, hydrocodone, acetaminophen, and gabapentin, were either not signed as given or not available. Staff interviews confirmed that medications were sometimes not administered or documented, and that some medications were not on hand despite being ordered and delivered. Another resident, admitted post-knee surgery with a history of osteoarthritis and mobility issues, also reported inadequate pain control and inconsistent receipt of prescribed pain medications. The resident stated that he had not received his prescribed pain medication for several days and rated his pain as severe. Review of medication records revealed missed doses and lack of documentation for several pain medications, including hydrocodone, gabapentin, and tramadol. Staff interviews indicated that medication orders were not always entered or documented in the medication administration record, and that medications were not always available when needed.