Failure to Provide Timely Pain Medication Results in Resident Harm
Penalty
Summary
A resident with chronic pain syndrome, hemiplegia, depression, and anxiety, who was cognitively intact, experienced almost constant pain rated at 8/10. The resident had physician orders for scheduled and PRN doses of acetaminophen and hydrocodone-acetaminophen, including specific instructions to administer these medications prior to a pre-scheduled surgery. Despite these orders, the medications were not administered before the resident left for surgery due to a lack of available supply, and there was no documented rationale for the omission in the resident's record. Staff identified that a new prescription for hydrocodone-acetaminophen was needed two days before the surgery, with only 10 tablets remaining at that time. The medication was not reordered in a timely manner, and the last available dose was given the night before surgery. Although staff contacted the pharmacy and requested a new script, the medication was not delivered before the resident's departure for surgery. The resident left the facility without receiving the ordered pain medications and arrived at the surgery center in severe pain, tearful, and expressing distress over not having received pain management. Documentation and interviews revealed that staff did not follow established protocols for timely medication reordering, did not escalate the issue to the provider or DON when the medication was unavailable, and failed to document the resident's refusal of alternative pain medication. The facility's policy required controlled medications to be reordered when a 5-7 day supply remained, but this was not adhered to, resulting in the resident experiencing actual harm due to unmanaged pain prior to surgery.