Failure to Follow Physician's Order for Pain Medication Administration
Penalty
Summary
Facility staff failed to follow a physician's order regarding pain management for a resident. The medical record review showed that the resident was prescribed an opioid 10 mg to be administered as needed every 4 hours, but only for pain levels rated between 7 and 10. Despite this, staff administered the medication on multiple occasions when the resident's documented pain level was below 7, including several instances where the pain level was recorded as 0 or 6, and once as low as 4. These deviations from the prescribed parameters were documented in the medication administration record for both May and June. During interviews, an LPN acknowledged awareness of the physician's order to administer the medication only for pain levels of 7-10 but admitted to giving the medication when the resident either did not provide a pain score or when a lower pain score was documented. The LPN also confirmed that no pain assessment was documented in the progress notes for these instances. The DON confirmed that staff were expected to assess and document the resident's pain level and administer medication according to the physician's parameters, acknowledging the concern when presented with the findings.