Failure to Administer Pain Medications Timely per Physician Orders
Penalty
Summary
The facility failed to ensure that two of five sampled residents received medication administration in accordance with professional standards and physician orders. Specifically, the facility did not administer scheduled pain medications, including Oxycontin and oxycodone, within the prescribed time frames for both residents. The medication administration records (MARs) showed multiple instances where medications were given outside the allowed one-hour window before or after the scheduled time, and in one case, a dose was missed entirely. One resident, who had diagnoses including fibromyalgia, neuropathy, and chronic pain, was cognitively intact and relied on scheduled opioid medications to manage severe pain. The MARs indicated that her Oxycontin doses were administered late on several occasions, sometimes by more than an hour past the scheduled time. The resident reported experiencing high levels of pain and noted that her pain medications were not always given on time, although she could not recall specific dates. Another resident, with diagnoses including dementia, chronic kidney disease, and chronic pain, also received scheduled pain medications. The MARs for this resident documented several late administrations of oxycodone, with one dose not administered at all. This resident expressed a desire not to experience any pain and stated that delayed administration of her pain medication resulted in increased discomfort. Staff interviews confirmed that the medications were not administered within the required time frames and acknowledged the importance of timely medication administration as per physician orders.