Failure to Administer Pain Medication as Ordered
Penalty
Summary
Facility staff failed to administer pain medication as ordered for a resident with chronic pain, resulting in missed doses of a Fentanyl transdermal patch. The resident, who was cognitively intact and able to make daily decisions, reported experiencing withdrawal symptoms such as nausea and diarrhea after not receiving her pain patch as prescribed. Documentation revealed that the Fentanyl patch was not administered for a 12-day period in March, and additional missed doses occurred in September, with gaps of up to six days between administrations. Medication administration records, narcotic sign-off sheets, and nurse's notes confirmed these missed doses, and there was a lack of documentation explaining the omissions on certain dates. The resident's care plan specified the need for analgesic medication to be administered as ordered and for monitoring of side effects and effectiveness every shift. Despite this, the facility did not ensure consistent administration of the Fentanyl patch according to physician orders. Interviews with staff and review of records verified the missed doses and lack of documentation for some scheduled administrations. The facility's pain management policy required provision of pain management services consistent with professional standards and the resident's care plan, but this was not followed in the resident's case.