F0697

G

Failure to Administer Ordered Migraine Medications and Monitor Pain/Blood Pressure

Bellaire, Ohio Survey Completed on 03-17-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement a comprehensive, individualized, and effective pain management program for a resident with a known history of severe, intractable migraines. The resident was admitted with diagnoses including migraine without aura, intractable, with status migrainosus, anxiety, depression, cerebrovascular disease, fibromyalgia, and hypertension. Admission orders included Aspirin, Gabapentin, Losartan, Metoprolol, and PRN Acetaminophen for pain. Early documentation showed incomplete vital signs and pain assessments on 11/26, and on 11/27 the resident reported posterior neck pain rated 4/10, occurring daily, with an assessment indicating she was alert and oriented. The care plan for potential alteration in comfort related to fibromyalgia directed staff to administer medications as ordered and per resident preference/request, encourage early reporting of pain, and observe for signs and symptoms of pain.

Over the next two days, the resident experienced escalating pain and migraine symptoms. On 11/27, an LPN documented administering Acetaminophen 325 mg (two tablets) for a headache unrelieved by environmental measures, with the medication noted as effective. On 11/28 at 3:16 A.M., another LPN documented the resident was vomiting and complaining of headaches causing her to vomit; Tylenol 325 mg (two tablets) was given and documented as effective. Later on 11/28, after discussion among the nurse, the resident, and the resident’s daughter with a nurse practitioner, new orders were obtained for Topamax for migraines, Imitrex PRN for acute migraines, Magnesium, and Perphenazine, along with a psychiatry consult. However, review of the MAR/TAR for November showed no evidence that Topamax or Imitrex were administered after these orders were written, and pain levels on 11/28 and 11/29 were marked as not applicable despite prior documentation of pain scores of 8 and 10 and the MDS indicating frequent severe pain affecting sleep and daily activities.

On 11/29, the resident’s daughter contacted the facility reporting that her mother had not received her medications. The assigned LPN later stated she was responsible for both Assisted Living and the skilled unit that day, and that when the daughter called, she told her she was preparing to pull the resident’s medications. The LPN acknowledged she did not administer Topamax because she believed it was scheduled for the afternoon and was unaware of the new Imitrex PRN order from the previous day. She confirmed that neither Topamax nor Imitrex had been administered and that she did not give PRN Tylenol for the resident’s headache, only the scheduled Gabapentin. The daughter subsequently arrived at the facility, found the resident covered in vomit with vomit on the floor, and requested transfer to the emergency room. The LPN obtained an order to send the resident to the hospital but did not complete a transfer form. Hospital records documented admission for intractable headaches with vomiting and hypertensive emergency, with an emergency room blood pressure of 200/100 mm/Hg and severe headache rated 9/10. The resident, her daughter, and the DON later confirmed that ordered migraine medications were not administered and that blood pressure monitoring was not performed as required, in contrast to the facility’s pain management policy, which required daily pain monitoring and assessment before and after PRN pain medication administration.

The resident and her daughter reported that the resident did not receive her migraine medications as ordered and that her blood pressure was not adequately monitored, leading to rehospitalization three days after admission. The daughter stated she frequently could not reach staff by phone and often could not find staff when visiting, and that her calls to the DON were not returned. The resident reported that she believed she was supposed to receive Hydralazine for migraines, as she had prior to admission and in the hospital, but did not think she was receiving all of her medications correctly at the facility. The DON confirmed that the resident did not receive her ordered medications and that staff failed to monitor her blood pressure, and the facility’s pain management policy specified recognition, evaluation, and management of pain consistent with assessment and care plan, including daily monitoring of pain levels and assessment of PRN pain medication effectiveness. These documented failures culminated in the resident’s transfer and hospitalization for intractable migraines with vomiting and hypertension.