Delayed Pain Management for Two Residents
Penalty
Summary
The facility failed to provide timely pain management for two residents, resulting in actual harm due to uncontrolled pain. Resident 9, who has diagnoses of Polyneuropathy and Chronic Pain Syndrome, experienced a significant delay in receiving prescribed pain medications. On December 28, 2024, Resident 9 was supposed to receive Methadone and Lyrica in the morning, but both medications were not administered until late afternoon, causing the resident to endure pain throughout the day. This delay was documented in a grievance filed by the resident, who reported having to request their routine morning pain medications and suffering from pain all day. Similarly, Resident 14, who has a diagnosis of Chronic Pain, also experienced a delay in receiving pain medication. Despite requesting Tramadol for pain relief at noon, the medication was not administered until 4:05 PM, after multiple requests. The resident's written statement indicated severe pain and consideration of hospital admission due to the delay. The Director of Nursing acknowledged the grievances and confirmed that the Nurse Practitioner/Physician was not informed of the late administrations until two days later. The nurse responsible for the delays was terminated on the day of the incident.
Plan Of Correction
Residents 9 and 14 were assessed and no adverse reactions, therefore no further adjustments to treatment was required per CRNP. A comprehensive review of current residents with scheduled pain medication ordered will be reviewed for the previous two weeks to ensure that pain medications were given as ordered and were effective. The Director of Nursing / Designee will educate licensed staff on F tag 0697 pain management, focusing on ensuring pain medications are administered at the prescribed time. Audits of 5 random residents with scheduled pain medication will be completed by unit managers / designee per week for 4 weeks to ensure pain medications are administered at.