Failure to Provide Timely Pain Management for Resident with Fractures
Penalty
Summary
The facility failed to provide timely and appropriate pain management for a resident with multiple fractures, including a displaced fracture of the right fibula and an unspecified fracture of the right tibia. Physician orders specified that Gabapentin 800 mg was to be administered four times daily at set times (8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM) for neuropathy. However, documentation showed that on two consecutive days, the resident's morning and noon doses were administered more than two hours late. The resident reported that despite using the call bell to notify staff of her pain and the delay in medication, her pain medication was not given on time. Review of the facility's medication administration policy revealed no guidance regarding the timeframe for administering medications relative to the ordered times. The DON confirmed that there was no policy specifying medication administration windows, but expressed an expectation that medications should be given within one hour before or after the scheduled time. The lack of a clear policy and the failure to administer pain medication as ordered resulted in the resident experiencing delays in pain relief.