Failure to Provide Ordered Pain Medication Due to Staff Inaction
Penalty
Summary
The facility failed to provide an ordered pain medication to a resident who was experiencing pain. The resident, who was cognitively intact and had diagnoses including hemiplegia, hemiparesis following cerebral infarction, and pain, reported back and foot pain and requested pain medication. The nurse on duty informed the resident that the pain medication was unavailable and that he would have to wait until it arrived. The nurse admitted to being distracted by another medical concern and did not follow through with obtaining the medication as needed and ordered, acknowledging this was her mistake. The facility had policies and procedures in place to address medication shortages, including obtaining medications from the pharmacy or the emergency medication supply, but these were not followed in this instance. Record review showed that the resident had an active prescription for Hydrocodone-Acetaminophen to be given every four hours as needed for severe pain. Documentation indicated a gap in administration of the medication, with the last dose given on one date and not administered again until two days later, despite the resident's ongoing pain. The administrator confirmed that the medication system was in place but was not utilized by the staff member, resulting in the resident not receiving the ordered pain medication.