Failure to Administer Prescribed Pain Medication and Document Refusals
Penalty
Summary
The facility failed to provide pain management as prescribed for a resident with large pressure ulcers who required pain medication during wound treatment. Medical record review and staff interviews revealed that the resident was not administered Tramadol every 8 hours as ordered, specifically missing the 2 pm dose on several consecutive days. The Medication Administration Record (MAR) indicated that the medication had been given, but a comparison with the Narcotics Record showed it had not actually been administered. Staff involved reported signing the MAR in error and believed the resident had refused the medication, but there was no documentation in the progress notes to support a refusal. The facility's expectation was that any refusal should be documented in the progress notes, which was not done in this case.