Failure to Maintain and Administer Ordered Pain Medication for Severe Orthopedic Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide effective pain management according to physician orders for one resident with significant orthopedic conditions. The resident was admitted and later readmitted with diagnoses including fractures of the lower end and shaft of the left tibia, difficulty in walking, and pain related to an internal orthopedic prosthetic device, implants, and grafts. Assessments documented that the resident had the capacity to understand and make decisions and was able to communicate needs, while requiring varying levels of assistance with ADLs such as dressing, toileting, showering, and hygiene. Physician orders on the resident’s Order Summary Reports included acetaminophen 325 mg, two tablets by mouth every four hours as needed for mild pain (1–4), and hydrocodone-acetaminophen 10-325 mg, one tablet every four hours as needed for moderate pain (5–7), and two tablets every six hours as needed for severe pain (8–9). A fax to the pharmacy requested refills of hydrocodone-acetaminophen for moderate to severe pain. Despite these orders, the Medication Administration Record for January showed that on one evening the resident was given only acetaminophen 325 mg, two tablets, for a documented pain level of 9, even though that medication was ordered only for mild pain (1–4). Interviews confirmed that the resident had not received the ordered hydrocodone-acetaminophen since a prior evening because the facility had run out of the medication. The resident reported current pain of 9 out of 10, stated that the Tylenol provided did not help, and indicated that he typically took his pain medication every six hours due to the severity of his pain. The LVN acknowledged discovering the medication was out on her first day back to work, stated that she usually reorders when six tablets remain, and confirmed she had administered Tylenol for a pain level of 9 despite its order being limited to mild pain, recognizing the possibility that the resident’s pain might not be alleviated. The DON stated that medications should never run out and that staff should maintain at least two to three days’ worth of medication, and recognized the potential for ineffective pain management based on the MAR review. The facility’s pain management policy required licensed nurses to administer pain medication as ordered and document it on the MAR.
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