Failure to Administer Physician-Ordered Pain Medication
Penalty
Summary
Facility staff failed to implement an effective pain management regimen for a resident who had a physician's order for Percocet 5/325 mg every four hours as needed for pain. Despite the order being present on the resident's Physician Order Sheet and care plan, staff did not administer the medication at any point during the months reviewed. The Medication Administration Record showed no documentation of Percocet being given, and progress notes did not indicate its use. Instead, the resident received Tylenol intermittently, which was documented as administered on select dates, but the stronger, physician-ordered medication was not provided. The resident, who had diagnoses including high blood pressure, dementia, schizophrenia, and depression, reported experiencing severe back pain that affected mobility and radiated down the leg. The resident stated that Tylenol was not effective and expressed a need for stronger pain relief, but was told by staff that only Tylenol was available. Interviews with staff revealed that the CNA reported the resident's pain to the nurse, and the LPN was unaware of the Percocet order, stating that it was not available on the medication cart and had never been administered. The interim Director of Nurses and the Administrator both confirmed they were unaware of the Percocet order, with the Administrator noting that the order had never been sent to the pharmacy. Facility policy required a systematic approach to pain recognition, assessment, and management, including administering medications as ordered and monitoring their effectiveness. However, the failure to transcribe and process the Percocet order resulted in the resident not receiving the prescribed pain management, despite ongoing complaints of severe pain and repeated communication with pain management providers.