Failure to Administer Ordered Pain Medication for Resident with Severe Pain
Penalty
Summary
A resident with multiple rib fractures, a history of falls, and hypertensive heart disease with heart failure was admitted to the facility and had a physician's order for hydrocodone-acetaminophen to be administered every four hours as needed for moderate to severe pain (pain level 4-10). The resident's Minimum Data Set indicated occasional pain at a level of six out of ten, and the Medication Administration Record documented a pain level of eight out of ten on a specific date. However, there was no documentation that the ordered pain medication was administered at that time. Interviews with the resident confirmed ongoing severe pain, particularly when being moved or turned, and that pain medication provided only short-term relief. The Assistant Director of Nursing and the Director of Nursing both acknowledged that the nurse should have administered the pain medication as ordered and that there was no documentation of administration or follow-up. Facility policies reviewed indicated that medications are to be administered according to prescriber orders and that pain should be addressed with appropriate interventions.