F0697

D

Failure to Administer Pain Medications as Ordered

Cleveland, Ohio Survey Completed on 03-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to administer ordered pain medications in a safe and timely manner to effectively manage a resident’s pain. The resident was cognitively intact, had chronic pain conditions including left hip pain, osteoarthritis of the left knee, lumbar disc degeneration, lumbar back pain, and right foot pain, and was care planned as being at risk for back pain, fatigue, anxiety, and bone pain with an intervention to administer medications as prescribed. Physician orders included scheduled oxycodone ER twice daily (upon rising and at 7:00 P.M.), PRN oxycodone doses, a daily lidocaine 4% patch upon rising, Lyrica 75 mg three times daily, and later Baclofen and methocarbamol as muscle relaxants. The facility’s policy required medications to be administered in a safe and timely manner and in accordance with ordered time frames.

Review of the medication administration audit reports and MARs for January and February showed numerous instances where the resident’s scheduled pain medications and related therapies were given late, given at times outside the defined administration windows, or not available and therefore not administered. Examples included Lyrica doses scheduled for 2:00 P.M. and 10:00 P.M. being given hours late or the following morning, lidocaine patches ordered for “upon rising” being applied in the early afternoon or evening, and oxycodone ER doses ordered for “upon rising” or 7:00 P.M. being administered late at night or the next morning. There were also documented instances where Lyrica doses at multiple times in a day were not available, and methocarbamol and oxycodone ER doses were not administered as ordered. On several dates, multiple scheduled medications (Lyrica, oxycodone ER, lidocaine patch, Baclofen) were consistently administered outside the facility’s defined time ranges for “upon rising,” “dinner,” and “bedtime.”

Nursing progress notes for January and February did not document reasons for the late administration of medications, except for the not-available notations for Lyrica on specific dates. Pain ratings documented on the MAR showed the resident reporting pain levels of six out of 10 and 10 out of 10 on multiple occasions during this period. The resident reported that pain medications were not always given on time, that she had chronic back pain, and that she needed her pain to be tolerable to participate in therapy with a goal of returning home, stating that pain at a level of five or six out of 10 was not tolerable without intervention. The DON confirmed the late administration times identified in the audit reports, stated she had never seen a medication administration audit report before, was not aware that medications were being administered late, and did not know why the resident’s pain medications were administered late.