Failure to Provide Timely PRN Pain Medication for Muscle Spasms
Penalty
Summary
A resident with a history of stress fracture of the right ankle and stage 3 chronic kidney disease requested a PRN dose of tizanidine for muscle spasms during the morning medication pass. The nurse, concerned about the risk of falls due to the medication's potential to lower blood pressure, asked the resident to wait until after lunch. The resident, who was non-weight bearing and used a wheelchair, expressed confusion about the fall risk but reluctantly agreed to wait and instead requested and received Xanax. The nurse did not return after lunch to check on the resident or offer the tizanidine, and the resident later reported increased spasms and pain, with observable signs of discomfort. Record review showed that the resident did not receive any further doses of tizanidine that day, and there was no documentation that the nurse followed up regarding the resident's need for the medication. The facility's pain management policy required pain medication to be given based on pain intensity and for the nurse to monitor the efficacy of pain management. The DON confirmed that the nurse should have followed up with the resident to see if the tizanidine was still needed, but this did not occur.