Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to implement physician orders for the administration of pain medication for one resident. The resident was admitted with multiple chronic conditions, including rheumatoid arthritis, and had a series of physician orders for Hydrocodone-Acetaminophen to be administered at specific intervals for pain management. Review of the medical administration record (MAR) showed that the pain medication was not documented as given according to the physician's orders. Progress notes indicated ongoing issues with obtaining the medication from the pharmacy and the facility's emergency drug kit (EDK), resulting in missed doses. Interviews with the Director of Nursing (DON) confirmed awareness of the issue and revealed that the resident's pain medication supply had run out, necessitating a new order for the pharmacy to provide additional medication or approve use from the facility's backup supply. The DON stated that it was expected for staff to reorder the medication before it ran out, but could not explain why this was not done. As a result, the resident did not receive pain medication as ordered by the physician.