Failure to Administer Pain Medication as Ordered
Penalty
Summary
Facility staff failed to administer pain management medication as ordered for a resident with moderately impaired cognition and multiple diagnoses, including pain, debility, anxiety, depression, and lung disease. The resident's physician had prescribed pregabalin 150 mg by mouth three times daily for pain, and the resident's care plan included both scheduled and PRN pain medications. Review of the medication administration record for April showed multiple missed doses of pregabalin on specific dates, with no documentation that the medication was given. During interviews, the resident reported not receiving pregabalin as prescribed during the last two weeks of April and experiencing pain while waiting for the medication. The ADON was unable to explain the gaps in administration and noted that the pharmacy was waiting for the physician to sign the order, while the Administrator confirmed that medications are expected to be administered as ordered. Facility policy requires implementation of the medication regimen as ordered and immediate provider contact if pain is not controlled, but these procedures were not followed, resulting in unnecessary pain for the resident.