Failure to Administer Pain Medication as Ordered
Summary
The facility failed to provide appropriate pain management for Resident 1, who was admitted with multiple complex medical conditions including peripheral vascular disease, chronic kidney disease, polyneuropathy, cellulitis, depression, and angina pectoris. Despite having a care plan that included administering hydromorphone for severe pain, the resident did not receive the medication as ordered on the evening of 4/18/24. The resident requested pain medication around 9-9:30 p.m., but the medication was not administered until 3:45 a.m. the following day, resulting in uncontrolled pain, increased agitation, and verbal aggression. The resident's care plan, initiated on 3/25/24, aimed for satisfactory pain control through both non-medication interventions and prn medications. However, on the evening of 4/18/24, the resident's request for pain medication was communicated by a CNA to LVN 1, who did not enter the resident's room or speak to the resident but instead assessed from a distance and concluded that the resident was not in pain. LVN 1 did not inform LVN 2, who was responsible for administering medications to the resident, about the pain medication request. As a result, the resident did not receive the hydromorphone dose from 9:30 p.m. to 12 midnight, with the last dose being administered at 5:49 p.m. The resident's pain escalated, leading to agitation and verbal aggression, and the resident eventually called 911 multiple times. The night shift nurse, LVN 3, noted that the resident usually received hydromorphone every four hours and had only received one dose that evening. LVN 3 had to request the RN to administer the medication due to the resident's severe agitation and aggression.
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