Failure to Administer Ordered Pain Medication After Resident Fall
Penalty
Summary
A deficiency occurred when a resident with a history of atherosclerotic heart disease, Alzheimer's disease, and osteoporosis experienced a fall and reported a pain level of six out of ten. The resident had a physician's order for Tylenol to be administered as needed for mild pain or general discomfort. Despite the resident's complaint of right hip pain and inability to move her right leg following the fall, no pain medication was administered prior to her transfer to a general acute care hospital. Record reviews confirmed that the Medication Administration Record (MAR) did not indicate any administration of Tylenol on the date of the incident, even though the resident's pain was documented. Interviews with nursing staff revealed that the licensed nurse on duty did not provide the ordered pain medication while the resident awaited paramedic transfer. Both the Risk Management Nurse and the Director of Nursing acknowledged that the resident should have been offered and administered pain medication according to the physician's order, and that this was not documented or carried out. Facility policy required licensed nurses to administer pain medication as ordered and document all medications given on the MAR, as well as to implement timely interventions to reduce pain severity. The failure to follow the physician's order and facility policy resulted in the resident not receiving appropriate pain management after the fall, as confirmed by staff interviews and record reviews.