Failure to Notify Physician of Missed Scheduled Pain Medication Doses
Penalty
Summary
The facility failed to ensure that a physician was notified of missed doses of scheduled pain medication for one resident. The resident, who had diagnoses including seizures, muscle weakness, anxiety disorder, major depressive disorder, and post-concussional syndrome, was on a strict pain management regimen with hydrocodone-acetaminophen scheduled every four hours. On two separate nights, the resident did not receive the 2:00 AM dose of pain medication because the nurse documented the resident as sleeping and did not attempt to wake her, despite the resident's stated preference to be woken for scheduled doses. There was no documentation in the care plan indicating the resident refused medications or did not want to be woken up, and the resident consistently expressed the importance of maintaining the medication schedule to prevent pain. Record review and staff interviews confirmed that the missed doses were not communicated to the resident's physician or representative, and there was no documentation in the progress notes regarding the missed medications. Facility staff, including the LPN, Unit Manager, and DON, acknowledged that the expectation was to attempt to wake residents for scheduled medications and to document any refusals or missed doses. The facility's pain management guidelines also required collaboration with the physician and documentation of interventions to manage pain, which was not followed in this instance.