Failure to Timely Administer PRN Pain Medication
Penalty
Summary
A deficiency occurred when a resident with a history of chronic pain, hidradenitis suppurativa, muscle weakness, and mobility issues did not receive prescribed pain medication in a timely manner. The resident had a physician's order for Oxycodone 15 mg every 4 hours as needed for pain. On the day in question, the resident last received the medication at 3:09 p.m. and was eligible for the next dose after 7:09 p.m. The resident requested the medication at approximately 8:00 p.m., but it was not administered until 9:58 p.m., resulting in a delay of 1 hour and 58 minutes. Facility policy requires that medications be administered safely, timely, and as prescribed, and that frequent PRN use be evaluated by the care team. Staff interviews and facility investigation revealed that the nurse on duty did not provide the medication promptly after the resident's request, citing personal safety concerns and workflow interruptions. The delay was confirmed by the Director of Nursing and the Administrator, who acknowledged that the nurse failed to administer the pain medication according to the physician's order. The incident involved multiple staff interactions and documentation of the resident's repeated requests and escalating distress prior to receiving the medication.