Failure to Administer Prescribed Pain Medications for Resident with Trigeminal Neuralgia
Penalty
Summary
A resident with a diagnosis of trigeminal neuralgia, a chronic and painful nerve condition, did not receive scheduled pain medications, including carbamazepine and lidocaine viscous solution, as ordered by the physician. The medication administration record showed missed doses over several days, and progress notes indicated that the pharmacy was notified of the need for refills, but the medications were not available or administered during this period. The resident reported increased pain and facial grimacing was observed by staff, with a pain score of nine out of ten documented on the morning following the missed doses. Staff interviews confirmed that the medications were not reordered in a timely manner, resulting in the resident not having access to her prescribed pain management regimen over the weekend. The resident's care plan included pharmacological interventions for pain but lacked direction for non-pharmacological interventions. The facility's pain management policy required individualized treatment plans with both pharmacologic and non-pharmacologic interventions for residents experiencing pain. Despite this, the resident's care plan was incomplete, and the failure to ensure timely medication refills and administration led to unmanaged pain for the resident.