Failure to Administer and Document Ordered Pain Medication
Penalty
Summary
The facility failed to ensure that narcotic pain medication was administered as ordered for a resident with a history of intermittent pain following a motor vehicle accident. The resident, who was cognitively intact and able to ambulate independently, had a physician's order for Oxycodone 5 mg every six hours for chronic pain. Despite this order, the Medication Administration Record (MAR) showed multiple missed doses of the prescribed pain medication on several dates across two consecutive months. There was no documentation in the resident's progress notes explaining why the pain medication was not administered or why pain assessments were not completed at those times. Facility policy required residents to be assessed for pain at specific intervals and when experiencing new or uncontrolled pain. The care plan for this resident included medicating for pain as ordered and following up for effectiveness. However, the facility did not document any assessments or reasons for withholding the medication on the missed dates. During an interview, the Director of Nursing confirmed that the expectation was for nurses to document the reason in the EMR if a routine pain medication was not given, which was not done in this case.