Failure to Provide Timely Pain Medication for Resident with Chronic Pain
Penalty
Summary
The facility failed to ensure that pain medication was available and administered as ordered for a resident with chronic pain and multiple complex medical conditions, including chronic pain syndrome, bipolar disorder, diabetes, and congestive heart failure. The resident had a physician's order for hydrocodone-acetaminophen 5-325 mg to be given three times daily. However, review of medication administration records and narcotic count sheets showed a gap of 16 hours between doses, despite the medication being scheduled every eight hours. The resident reported experiencing significant pain during this period and stated that running out of pain medication was a recurring issue. Staff interviews revealed that the nurse did not reorder the pain medication in a timely manner, despite being informed by the resident that the supply would not last through the weekend. The DON initially stated that the stock supply was depleted, but later clarified that the medication was available in the stock kit, though it was not accessed due to procedural issues. The facility did not contact the physician to obtain a one-time order from the contingent supply, resulting in the resident missing scheduled doses and experiencing unmanaged pain.