Failure to Administer and Document Physician-Ordered Pain Medications
Penalty
Summary
The facility failed to follow physician orders and ensure that as-needed pain medications were administered to residents as prescribed, affecting two residents with significant pain management needs. One resident with a complex medical history, including malignant neoplasm of bone, osteomyelitis, and a lumbar vertebrae fracture, reported that his pain was not managed well due to inconsistent administration of his prescribed medications. Documentation showed that several medications, such as lidocaine patches and gabapentin, were either not signed out as given or not available, despite being delivered by the pharmacy. The resident described experiencing excruciating pain and stated that staff did not understand his needs, with records confirming missed doses and incomplete documentation in the medication administration record (MAR). Another resident, admitted after knee surgery and with diagnoses including osteoarthritis and muscle weakness, also did not receive pain medications as ordered. The resident reported not receiving Norco consistently and rated his pain as severe. Review of the MAR confirmed that Norco was not administered for several days, and there was no documentation of tramadol administration, despite a physician order. Staff interviews revealed confusion regarding medication availability, lack of documentation, and failure to reorder medications in a timely manner. The nurse practitioner confirmed that orders were given, but the medications were not documented as administered, and the DON acknowledged lapses in documentation and medication management. Facility policies required that all medications be administered as ordered, with proper documentation in the MAR, and that pain management be based on resident reports and physician orders. However, the facility did not adhere to these policies, resulting in residents experiencing unmanaged pain and psychosocial harm. The failure to document medication administration and ensure medication availability directly contributed to the deficiency, as evidenced by resident statements, staff interviews, and review of medical records.