Failure to Administer Pain Medications According to Physician Orders and Protocols
Penalty
Summary
Two residents experienced deficiencies related to the administration of medications that were not in accordance with physician orders and facility protocols. One resident, who was cognitively intact and had a history of chronic back pain and related diagnoses, was prescribed acetaminophen-codeine to be administered for severe pain. However, nursing staff administered this medication 21 times over several days for pain levels documented as 0-6 out of 10, which corresponded to no pain, mild, or moderate pain, rather than severe pain as specified in the order. The medication administration records and interviews with nursing staff, the pharmacy consultant, and the Director of Nursing confirmed that the medication was repeatedly given outside the prescribed parameters, and the pain scale was not properly used to guide administration. Another resident, who had a history of a recent fall and was described as alert but confused, was administered acetaminophen for complaints of pain and headache. The physician's order for this medication specified it was to be given only for temperatures above 101 degrees Fahrenheit, not for pain. Despite this, nursing staff administered the medication for pain on at least two occasions. Both the pharmacy consultant and the Director of Nursing confirmed that the medication was not administered according to the physician's order, and that staff should have contacted the physician for an appropriate pain management order instead of using the medication off-label. Facility policies and procedures reviewed during the investigation emphasized the importance of assessing pain accurately, following medication administration instructions, and adhering strictly to prescriber orders. The failures identified in both cases were confirmed through interviews, record reviews, and direct observation, demonstrating that staff did not follow established protocols or physician instructions in the administration of pain medications for these residents.