Failure to Administer Ordered Pain Medication Due to Prescription Renewal Delay
Penalty
Summary
A resident with multiple chronic conditions, including multiple sclerosis, chronic pain, and paraplegia, was admitted to the facility and had a care plan that included both scheduled and as-needed pain medications. The resident was prescribed Lyrica 100 mg twice daily for pain, among other pain management medications. Review of the medication administration record revealed that the resident did not receive six scheduled doses of Lyrica over several days. Documentation showed that some doses were held without a reason, while others were not administered because the medication was on order or awaiting a prescription renewal from the nurse practitioner. Progress notes indicated a delay in obtaining the necessary prescription, resulting in missed doses. Interviews with the resident confirmed that the missed doses led to increased pain and more frequent, severe headaches during the period when Lyrica was not administered. Nursing staff and the Assistant Director of Nursing acknowledged that there was a miscommunication regarding the timely renewal of the prescription, which led to the interruption in pain management. Facility policy required pain to be managed according to the care plan and professional standards, but the failure to ensure timely medication renewal and administration resulted in the resident not receiving ordered pain management as required.