Failure to Notify Physician and Document Acute Pain Complaint
Penalty
Summary
A resident with multiple significant diagnoses, including cirrhosis of the liver, diabetes mellitus type II, cardiomyopathy, unspecified convulsions, difficulty with walking, and glaucoma, reported acute stomach pain to a senior regional nurse consultant. The resident also expressed concerns that two night nurses were not providing water or pain medication. At the time, the resident did not have any physician orders for pain medication, and his care plan included interventions for pain management, such as asking for medication and having pain levels reviewed every shift. On the night in question, the registered nurse (RN) on duty was aware of the resident's pain complaint but did not notify the on-call physician to obtain an order for pain medication. The RN cited concerns about the resident's abnormal lab values, specifically elevated liver enzymes and low platelets, as reasons for not administering acetaminophen or ibuprofen. Instead, the RN offered non-pharmacological interventions, such as repositioning, which the resident refused. The RN did not document the resident's pain complaint, the interventions offered, or the resident's refusals in the progress notes. The RN reported the situation to the oncoming nurse but did not take further action to address the resident's pain during her shift. Interviews with facility staff revealed that the process for contacting the on-call physician was not clearly posted or included in the nurse orientation checklist at the time of the incident. The director of nursing expected that nurses would notify the on-call physician if a resident without pain medication orders complained of pain, but this expectation was not met. The lack of timely physician notification and absence of documentation regarding the resident's pain and interventions led to the deficiency in providing safe and appropriate pain management.