Failure to Administer Pain Medications and Reassess Smoking Privileges
Penalty
Summary
Facility staff failed to ensure that a resident received pain medications as ordered following the postponement of a scheduled surgery. The resident, who was cognitively intact and diagnosed with Parkinson's Disease and osteoporosis, had a care plan that included scheduled and PRN pain medications. After the surgery was canceled, staff did not obtain a physician's order to resume medications that had been placed on hold, nor did they document an order for the medication holds or their resumption. The electronic Medication Administration Record (eMAR) showed that pain medications such as Tizanidine and Hydrocodone/Acetaminophen were not administered on several occasions, with reasons documented as either "not available" or "on hold." The resident and family were told by charge nurses that no medications were on hold, but the resident later learned from a Certified Medication Technician that Tizanidine was on hold, resulting in unmanaged pain and confusion about medication administration. Interviews with staff revealed a lack of clarity and communication regarding medication holds and resumption after surgery cancellation. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) acknowledged that medication holds were not properly managed and that staff did not obtain the necessary physician orders. The DON stated that medication holds and resumptions were typically communicated during shift reports or through notes, but this process failed when the nurse responsible for the holds left the facility. Additionally, staff did not utilize the STAT box to obtain unavailable pain medication, further contributing to the resident not receiving prescribed pain management. The facility also failed to complete and document smoking risk assessments to re-assess smoking privileges for two residents who smoke. Despite incidents where one resident was observed smoking inside the building and another was involved in a dispute over cigarettes, there was no documentation of re-assessment of their smoking privileges in the electronic medical record. Interviews with staff and administration indicated confusion over who was responsible for completing smoking assessments, with inconsistent practices and lack of follow-through when incidents occurred.