Failure to Administer and Accurately Document Pain Medication
Penalty
Summary
Resident 11, who had the capacity to make medical decisions, was readmitted to the facility and had physician orders for two types of lidocaine patches: Asperflex Lidocaine 4.0% to be applied to the lower back and Lidoderm 5% to be applied to the right hip, both for pain management. The facility's policies required medications to be administered as prescribed, documented immediately after administration, and not pre-poured or shared between residents. Medical records indicated that the patches were documented as administered and removed at scheduled times on multiple days. However, direct observation and interviews revealed that Resident 11 did not receive the lidocaine patches on two consecutive days, despite documentation on the MAR indicating otherwise. The DON confirmed that the patches were not applied and that the medication cart still contained the full supply of patches, which had not been refilled or used as documented. The discrepancy was further verified by pharmacy records and staff interviews, confirming that the resident did not receive the prescribed pain management as ordered.
Plan Of Correction
- Disposition record logs to verify compliance. Visual checks that patches have been applied to the residents. The results of these audits will be presented to the QAPI Committee on a quarterly basis for further monitoring and/or action planning as needed. Completion Date: 10/25/2025