Failure to Administer Scheduled Comfort Medication per Physician Order
Penalty
Summary
Facility staff failed to administer scheduled doses of comfort medication, specifically morphine, as ordered by the physician for a resident with diagnoses including dementia, COPD, atrial fibrillation, heart disease, and anxiety disorder. The physician had changed the morphine order from as-needed to scheduled every four hours to address increased pain and agitation. Despite this, Qualified Medication Aides (QMAs) did not administer several scheduled doses, documenting reasons such as the resident having no pain, being asleep, or being unable to be aroused. In some instances, the medication was withheld because the resident appeared comfortable or was unable to take the medication due to clenching teeth, and family members were present and agreed with the decision to hold the dose. The clinical record did not contain documentation of nursing assessments justifying the omission of scheduled doses, nor was there evidence that the physician was notified when doses were held. Interviews with QMAs confirmed that they made independent decisions to withhold scheduled morphine based on their observations and family input, without completing required assessments or contacting the physician. The facility's policy required that physician orders be followed and that staff notify the physician if scheduled medications were not administered, which was not done in these instances.