Failure to Administer Scheduled Pain Medication as Ordered
Penalty
Summary
A deficiency occurred when a resident with systemic lupus erythematosus and chronic pain syndrome did not receive scheduled pain medication as ordered by the physician. The resident's care plan and physician orders specified acetaminophen 1000 mg to be administered three times daily at 6 a.m., 2 p.m., and 10 p.m. However, review of the Medication Administration Record (MAR) revealed that the 10 p.m. dose was not administered from the 1st to the 7th of the month, and the medication was instead given at 10 a.m. and 2 p.m. This discrepancy was confirmed by both the Registered Nurse Supervisor and a Licensed Vocational Nurse, who stated that the medication was not given according to the prescribed schedule. The failure to administer the pain medication as ordered was attributed to a transcription error in the MAR, which was overlooked by the admitting nurse and resulted in the resident not receiving the scheduled nighttime dose. The resident occasionally experienced moderate pain, as indicated by a pain rating of four out of ten, and the facility's policy required administration of pain medication as ordered for such pain levels. The error was identified during interviews and record reviews, where staff acknowledged the incorrect administration times and the potential for ineffective pain management.