Failure to Administer Pain Medication as Ordered
Penalty
Summary
Facility staff failed to follow provider orders for a resident with multiple diagnoses, including congestive heart failure, COPD, muscle weakness, and neuropathy. The resident had impaired mobility and was dependent on staff for most activities of daily living. The resident had been prescribed Neurontin 100 mg capsules for neuropathy pain, which was reported by the family to be effective in managing the resident's burning and pain. However, the medication was stopped without discussion with the family, and the resident's pain returned. The family brought the issue to the attention of staff after noticing the resident's increased pain. Review of the medication administration records and interviews revealed that the provider had ordered Neurontin 100 mg three times daily after a two-week evaluation period, and this order was documented as received by the facility. Despite this, the medication was not administered from the date the order was received until several days later. Staff were unable to explain how the order was missed during this period, resulting in the resident experiencing unnecessary pain due to the lapse in medication administration.