Failure to Maintain Ordered Pain Medication Supply and Proper Administration
Penalty
Summary
The facility failed to ensure a resident was free of significant medication error when ordered pain medications were not administered as prescribed. The resident was admitted and later readmitted with multiple left tibia fractures, difficulty walking, and pain related to internal orthopedic prosthetic devices, implants, and grafts. The resident’s history and physical and MDS documented that the resident was cognitively able to understand and make decisions, and required varying levels of assistance with ADLs, but did not indicate cognitive impairment that would prevent reporting pain. The resident had physician orders for 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 the hydrocodone-acetaminophen prescriptions. Review of the MAR for January showed that on one evening, the resident was administered acetaminophen 325 mg, two tablets, for a documented pain level of 9, even though this medication was ordered only for mild pain levels of 1–4. In interviews, the resident reported being told that the facility had run out of the ordered hydrocodone-acetaminophen and stated not having received it since a prior night. The resident reported current pain at 9 out of 10, described it as very bad and causing a headache, and stated that the prescribed pain medication was normally taken every six hours “on the dot” due to the severity of the pain, but that only Tylenol had been given and it did not help. The LVN acknowledged discovering that the resident was out of pain medication on her first day back to work, stated that she usually reorders when six tablets remain, confirmed that a refill request had been faxed, and admitted giving Tylenol for a pain level of 9 despite the order limiting it to pain 1–4. The DON stated that medications should never run out and that staff should maintain at least two to three days’ worth of medication, and identified a potential for ineffective pain management when reviewing the MAR entry. Facility policies on pain management and medication reordering required administration of pain medications as ordered and timely refills via the EMAR system or fax to the pharmacy.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.