Failure to Provide Ordered Pain Management
Penalty
Summary
The facility failed to provide pain management as ordered for a resident with a history of orthopedic aftercare, right artificial hip joint, history of malignant neoplasm of ovary, and osteoarthritis. The resident's care plan included interventions to administer pain medications as ordered and to assess pain as needed. Physician orders specified Oxycodone 10 mg every four hours as needed for severe pain. Documentation showed that the medication was administered on one occasion, but subsequent doses were not recorded on the Medication Administration Record (MAR) despite being signed out on the controlled drug record. On one occasion, the resident was observed tearful and reported being unable to attend therapy due to pain, stating she was told her pain medication order had expired and was awaiting a refill from her physician. The Unit Manager initially stated the pain medication order was for three days and had ended, and described the resident as drug seeking. Later, the Unit Manager clarified that the order had no stop date and sought clarification from the physician. The Director of Nursing confirmed that nurses are expected to follow physician orders and assess pain as needed. The failure to administer pain medication as ordered and to accurately document administration resulted in the resident experiencing unmanaged pain and missing therapy.