Failure in Pain Management for a Resident
Penalty
Summary
The facility failed to provide effective pain management for Resident R16, who was admitted with a right below-the-knee amputation, diabetes, and peripheral vascular disease. The resident's care plan included administering medication per physician orders to manage pain. However, despite a physician's order dated April 11, 2025, to administer 15 mg of MS Contin three times a day, the resident did not receive the medication as scheduled on multiple occasions due to it not being in stock. Interviews and clinical record reviews revealed that Resident R16 experienced phantom pain and had not received the prescribed morphine for pain management. The resident expressed uncertainty about the medication's availability, and the Director of Nursing confirmed the facility's failure to provide the necessary pain management. This deficiency was identified during a review of four residents, highlighting a lapse in the facility's adherence to professional standards of practice and the resident's care plan.
Plan Of Correction
1. The facility is unable to go back and make certain physician orders were followed and a resident received treatment and care in accordance with professional standards of practice. Resident R16 had no negative outcomes. 2. DON/designee will complete a 30-day lookback of all current resident's medication list, and audit carts for medication availability. 3. DON/designee to educate licensed staff on emergency medication supply, access to emergency medication supply, physician notification requirements of meds not available, and documentation requirements. 4. DON to audit medication availability 5x/week for 2 weeks, then 3x/week for 2 weeks, and 1x/week for 2 weeks. 5. Results to be submitted to QAPI for review and approval.