Resident Not Informed of Pain Medication Change
Penalty
Summary
A resident was admitted to the facility with a history of a right femur fracture, right hip dislocation, and required assistance with personal care. Upon admission, the resident was prescribed tramadol for pain management, as indicated in the discharge documentation from the previous hospital. The resident was assessed as moderately impaired in cognitive skills but was determined to have the capacity to understand and make decisions regarding care and treatment. On the day following admission, the resident's pain medication was changed from tramadol to norco by physician order. The resident was not informed of this change and only discovered the switch when requesting pain medication. During interviews, the resident stated that nursing staff did not notify them of the change, and review of the medical record confirmed there was no documentation of resident notification. Facility policy requires residents to be informed of and participate in care planning and treatment, but this was not followed in this instance.