Failure to Administer Pain Medication as Ordered
Penalty
Summary
A deficiency occurred when a resident did not receive pain medication as prescribed following a change in their medication order. After a nurse practitioner increased the resident's Hydrocodone-Acetaminophen dose from 5 mg to 7.5 mg, staff continued to administer the original 5 mg dose for approximately one week. This error was due to staff not removing the discontinued 5-325 mg medication card and instead placing the new 7.5-325 mg card behind it, resulting in the continued administration of the lower dose despite the updated physician's order. The resident reported that they were informed by the DON that the incorrect dose had been given for a week. Medication administration records and controlled drug receipt records confirmed that the resident received the lower dose during this period. The facility's policy requires medications to be administered accurately according to physician orders, but this was not followed, leading to a significant medication error involving the administration of the wrong dose of pain medication.