Failure to Accurately Enter and Administer New Pain Medication Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate ordering, entry, and administration of prescribed pain medications for one resident. The resident was an older female admitted with multiple serious diagnoses, including Type 2 diabetes, chronic kidney disease, nonalcoholic cirrhosis, lumbar compression fracture, malignant breast cancer, and recurrent depressive disorders. Her MDS showed moderately impaired cognition (BIMS 12) and functional impairment in both upper extremities. Her care plan stated she would participate in making choices and decisions regarding pain management. Physician orders dated 01/10/2026 at 5:00 p.m. included Tramadol 50 mg by mouth every 6 hours as needed for pain, a Fentanyl 12 mcg/hr patch every 72 hours, and Methocarbamol (Robaxin) 500 mg by mouth every 8 hours for pain, with Hydrocodone-Acetaminophen discontinued at that time. Review of the MAR showed Tramadol PRN was administered on 01/11/2026 at 5:00 p.m., the Fentanyl patch was administered on 01/11/2026 at 7:42 a.m., and the Robaxin order, received on 01/10/2026 at 5:00 p.m., was not entered into the resident’s orders until 01/12/2026, with Robaxin first administered on 01/12/2026 at 12:00 a.m. The MAR reflected one missed dose of Robaxin on 01/11/2026 and two missed doses on 01/12/2026. During interviews, the resident reported that her daughter told her she had not received her pain medication on Saturday night and recalled her pain level as 5 out of 10, though she did not request pain medication and stated she believed the Fentanyl patch was helping. A family member reported the resident was without pain medication from the afternoon of 01/10/2026 until the afternoon of 01/11/2026. The DON stated that Robaxin was ordered and should have been given the same day the order was received, but none was given, and that Tramadol PRN was ordered and not given until later. The DON explained that LVN A changed the orders in the electronic system to discontinue Hydrocodone but forgot to enter the scheduled Robaxin order. LVN A confirmed she received the new orders by text, was responsible for updating the chart, and acknowledged not updating the orders immediately, despite the expectation that new medications be started as ordered. Facility policy required that new medication orders be documented with date, time, and signature, recorded on the physician’s order sheet and MAR, and that changed orders be correctly entered in the electronic system, which did not occur in this case.
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