Failure to Administer Ordered Hydrocodone-Acetaminophen for Post-Surgical Pain
Penalty
Summary
Facility staff failed to implement a complete pain management program for Resident #173 by not administering Hydrocodone-Acetaminophen as ordered following admission. The resident had a recent laminectomy with a surgical wound and was assessed on the admission MDS as having a surgical wound, receiving scheduled pain medication, and experiencing occasional pain. The emergency room discharge summary and subsequent physician orders specified Hydrocodone-Acetaminophen 5-325 mg by mouth every four hours for pain for a defined period. The eMAR showed the medication was scheduled to begin on 3/29/2024 at 4:00 PM but documented multiple missed doses from the evening of 3/29/2024 through the afternoon of 3/30/2024. Progress notes indicated that on the evening of admission the pharmacy reported not receiving the faxed or e-scribed prescription, and repeated follow-up calls to the pharmacy revealed that no prescription had been received. The on-call provider reported not having access to send the prescription until the following morning and instructed staff to hold the medication until then. Despite the facility having an in-house stock of Hydrocodone-Acetaminophen 5-325 mg tablets and a system allowing nurses to obtain a code from the pharmacy to access these medications, including narcotics, the resident did not receive the ordered pain medication during this period. The resident’s care plan identified actual impaired skin related to laminectomy and pain related to a surgical wound, with an intervention to treat pain per orders prior to treatment or turning, but the ordered pain medication was not provided as scheduled.
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