Failure to Provide Timely Pain Management Due to Medication Order Process Lapse
Penalty
Summary
The facility failed to provide appropriate pain management for one resident following admission from an acute care hospital. The resident, who had recently undergone neck surgery and had diagnoses including orthopedic aftercare, muscle weakness, and cervical spinal stenosis, was assessed as having pain at a level of five out of ten. The resident's Minimum Data Set indicated the use of PRN pain medication, with pain described as occasional but severe enough to interfere with sleep. A physician's order for oxycodone-acetaminophen was present in the medical record, but the medication was not administered as needed after admission. Interviews and record reviews revealed that the facility did not receive the required hard copy prescription for the narcotic pain medication from the hospital, and the receiving nurse did not contact the physician to obtain an alternative order for pain relief. As a result, the resident did not receive any pain medication during the night after admission, despite complaints of pain. The Director of Nursing confirmed that the facility's process required a hard copy prescription to access emergency medication stock, but this was not followed, and the necessary steps to ensure pain management were not taken.