Failure to Timely Administer Scheduled Pain Medication
Penalty
Summary
The facility failed to ensure timely administration of pain medication for a resident with chronic pain related to cancer and pathological fractures. The resident, who had intact cognition and required significant assistance with activities of daily living, was admitted with multiple serious diagnoses including malignant neoplasms and malnutrition. Physician orders specified scheduled administration of Morphine Extended Release twice daily, but the resident did not receive any scheduled doses on the first two mornings after admission. Instead, the resident received a single dose of Acetaminophen, which was ineffective in managing the reported pain, and there was no documentation of alternative interventions while awaiting the prescribed morphine. Interviews with nursing staff confirmed that the pharmacy delivered medications twice daily and that some medications were kept in stock for immediate use. Staff also indicated that emergency pharmacy deliveries were possible for urgent needs. Despite these procedures, the resident's medication was not administered as ordered, and the missing doses were verified by the Director of Nursing. Facility policies required assessment and management of pain and documentation of any medication delivery discrepancies, but there was no evidence these policies were followed in this instance.