Failure to Administer Pain Medication as Ordered
Penalty
Summary
Facility staff failed to administer pain medication according to practitioner orders for two residents. For one resident with moderate cognitive impairment and significant assistance needs, gabapentin was discontinued per neurology orders, but Lyrica, which was to be continued, was incorrectly placed on hold by the pharmacy. Despite staff contacting the pharmacy multiple times, the Lyrica was not reinstated, resulting in the resident missing nine doses over several days. The resident subsequently became more confused and stopped eating, and it was noted that the abrupt discontinuation of both medications led to withdrawal symptoms. For another resident with congestive heart failure and extensive care needs, there was a failure to change a prescribed buprenorphine patch for chronic pain management as ordered. The patch, which should have been changed weekly, remained in place for twelve days, resulting in a missed dose. This omission was confirmed by facility staff and documented in the resident's medical records.