Failure to Administer Prescribed Pain and Anxiety Medications
Penalty
Summary
A deficiency occurred when a resident with chronic lymphocytic leukemia, congestive heart failure, and generalized anxiety, who was on hospice care due to declining health, did not receive prescribed medications for pain and terminal restlessness. Following a fall that resulted in a left femur fracture, the resident was ordered morphine sulfate and lorazepam to manage pain and restlessness. However, clinical records and the Medication Administration Record (MAR) showed that several scheduled doses of morphine and one dose of lorazepam were not administered as ordered over a specified period. The agency nurse assigned to the resident reported discomfort with administering both medications together, citing an assessment that did not show signs of restlessness, and therefore withheld the medications. The Director of Nursing's investigation confirmed that multiple scheduled doses were missed. The Nursing Home Administrator acknowledged that the medication orders were not followed, and the agency nurse was not permitted to return to the facility. This failure to administer prescribed medications as ordered constituted neglect, as the resident was not protected from the willful withholding of necessary care.