Failure to Timely Administer Ordered Pain Medication
Penalty
Summary
A resident with a history of trauma resulting in necrotizing fasciitis of the left upper and lower extremities was admitted for skilled nursing care and rehabilitation. The resident underwent multiple surgical procedures, including debridement, fasciotomy, and a muscle flap graft, and required a Wound VAC. The resident's pain management regimen included Oxycodone 10 mg every four hours as needed, with the last dose documented prior to admission. Upon admission, the resident requested Oxycodone, and the admitting nurse confirmed the medication was ordered and could be accessed from a backup supply until the pharmacy order was filled. Despite repeated requests by the resident and assurances from nursing staff that the medication would be provided, the resident did not receive the ordered Oxycodone as scheduled. Record review showed that the Medication Administration Record (MAR) had an active order for Oxycodone 10 mg every four hours as needed for pain, starting on the day of admission. However, there was no documentation of administration on that day, and the controlled substance record confirmed that the resident did not receive the medication as ordered. The Director of Nursing acknowledged that the Oxycodone was not provided according to the physician's order, and the resident did not receive the first dose until the following evening, resulting in a significant delay in pain management.