Failure to Administer Prescribed Pain Medications Resulting in Uncontrolled Pain
Penalty
Summary
The facility failed to administer prescribed opioid medications, muscle relaxants, and anticonvulsants for pain control to two residents with significant pain-related diagnoses. Both residents had documented orders for medications such as Xtampza ER, oxycodone, morphine, baclofen, gabapentin, and Lyrica, which were not administered as prescribed due to medications being out of stock, insurance issues, and pharmacy transition problems. Medication Administration Records and Controlled Substances Proof of Use showed multiple missed doses and blank entries, indicating that the medications were not given as ordered. One resident, with a history of cervical spinal cord injury and chronic pain syndrome, experienced ongoing, uncontrolled, and severe pain, rating it as a 9 out of 10. The resident reported that when pain medications were unavailable, the pain remained severe until the medication was finally received, and no alternative interventions were provided. The resident was dependent on staff for activities of daily living and had a care plan specifying the need for timely pain medication administration and evaluation of effectiveness, which was not followed. Another resident, diagnosed with spinal muscular atrophy, restless leg syndrome, neuralgia, neuritis, and muscular dystrophy, also did not receive prescribed pain medications due to similar issues. This resident experienced excruciating, continuous pain and withdrawal symptoms, leading to an emergency room visit for pain relief. Staff interviews confirmed awareness of the medication shortages and the impact on residents, with documentation that the medications were not administered from emergency kits or pyxis. The facility's own policy required medications to be administered as ordered and documented, which was not adhered to in these cases.