Failure to Provide Adequate Pain Management
Penalty
Summary
The facility failed to provide adequate pain management for a resident, identified as Resident 62, who was cognitively intact and required assistance for daily care needs. The resident had a physician's order for a 10 mcg/hr Butran's patch to be changed every seven days for pain management. However, the Medication Administration Record (MAR) for December 2024 indicated that the Butran's patch was not available on December 4 or December 11, 2024, resulting in the resident not receiving the pain patch since November 27, 2024. This lack of availability led to the resident experiencing more pain than usual over the last two weeks, as confirmed during an interview with the resident on December 9, 2024. The facility's policy on pain management, dated January 14, 2019, required staff to implement a pain management program, including evaluation and re-evaluation for residents experiencing pain. Despite this policy, there was no documented evidence that nursing staff made efforts to provide effective pain management for Resident 62 when the pain patches were unavailable. An interview with the Director of Nursing on December 12, 2024, revealed that the pharmacy had an issue with the resident's insurance, delaying the delivery of the patches. Additionally, there was no evidence that alternative pain relief was offered to the resident during this period.
Plan Of Correction
1. The Director of Nursing contacted the pharmacy regarding resident 62 and the Butrans patch were delivered the same day. 2. Baseline audit of pain medication completed. 3. The Interdisciplinary team will review administration of pain medications during morning clinical meeting to determine pain medication effectiveness or need for further evaluation of treatment. The Director of Nursing /designee will educate licensed nursing staff including agency on the process for medication availability during a medication pass. 4. To maintain and monitor compliance, a weekly audit will be conducted by the Director of Nursing or designee for four weeks, then monthly for two months, to ensure resident's pain medications are available or the physician has been notified to obtain further recommendations. Results of this audit will be reviewed by the Quality Assurance and Improvement Committee for additional recommendations if necessary.