Failure to Administer Scheduled Pain Medication as Ordered
Penalty
Summary
The facility failed to ensure that a resident received scheduled pain management treatment in accordance with professional standards of practice and the resident's care plan. The resident, who had a history of chronic pain related to bilateral lower extremity amputation, joint pain, muscle wasting, and diabetic neuropathy, was prescribed Biofreeze Gel 4% to be applied to his hands twice daily at 8:00 am and 8:00 pm. Review of the Medication Administration Record (MAR) showed that the medication was frequently administered outside the required one-hour window before or after the scheduled time, and on several occasions, it was not administered at all, including a full day when no doses were given. Interviews with the resident revealed that he often requested his pain medication from CNAs, but the requests were not always relayed to the nursing staff. The resident reported not receiving his Biofreeze as ordered and had to approach the nurses' station to ask for it. Observations confirmed that the resident was actively seeking his medication from staff. Nursing staff interviews indicated confusion regarding documentation of refusals and the timing of administration, with staff sometimes delaying administration based on the resident's preference but without a corresponding physician order to allow for such flexibility. Staff also failed to document refusals appropriately, and there was no evidence that the physician was consistently notified when the resident did not take the medication as scheduled. Facility policy required that scheduled medications be administered within one hour before or after the scheduled time, which was not consistently followed for this resident. The Director of Nursing and other staff acknowledged the deviations from policy and the lack of adherence to the physician's order for scheduled administration. The failure to provide the medication as ordered and within the required timeframe resulted in the resident not receiving consistent pain management as outlined in his care plan.