Failure to Administer Scheduled Pain Medication and Notify Physician/Family
Penalty
Summary
A deficiency occurred when the facility failed to ensure that scheduled pain medications were administered as ordered and that appropriate notifications were made to the physician and family representative for a resident requiring consistent pain management. The resident, who had diagnoses including seizures, muscle weakness, anxiety disorder, major depressive disorder, and post-concussional syndrome, was on a strict regimen of hydrocodone-acetaminophen every four hours to prevent pain, as per physician orders. On two occasions, the resident did not receive the scheduled 2:00 AM dose because the nurse documented the resident as sleeping and did not attempt to wake her or provide the opportunity to refuse the medication. Interviews with staff, including the Unit Manager, LPN, and DON, confirmed that the facility's policy requires staff to attempt to wake residents for scheduled medications and to notify the physician and family representative if a dose is missed or refused. However, there was no documentation of any such attempts or notifications for the missed doses. The resident herself reported waking up in pain and expressed the importance of maintaining her medication schedule to prevent breakthrough pain. A review of the resident's care plan and progress notes revealed no documentation regarding medication refusals or instructions not to be woken for medications. The facility's pain management guidelines and medication administration policy both emphasize the need for consistent pain management, proper documentation, and communication with the physician and family representative when scheduled medications are missed. These procedures were not followed in this case, resulting in the identified deficiency.