Failure to Provide Timely and Effective Pain Management
Penalty
Summary
The facility failed to provide effective pain management for a resident who had multiple traumatic injuries, including fractures and recent bladder surgery. The resident was prescribed hydromorphone for moderate to severe pain, with orders to administer the medication as needed and to assess and document pain levels before and after administration. Despite these orders, the resident repeatedly reported severe pain and did not receive timely administration of hydromorphone. On several occasions, the medication was not available, and staff did not access the emergency medication kit promptly or document pain assessments and follow-up evaluations as required by facility policy. Record reviews revealed gaps in pain assessment documentation and medication administration. The resident's pain flow sheets and medication administration records showed missing entries for pain levels and interventions on multiple days, and there was no evidence of reassessment of pain within two hours after medication was given. Interviews with nursing staff indicated confusion about procedures for accessing the emergency medication kit and delays in obtaining pharmacy authorization, resulting in the resident experiencing prolonged periods of uncontrolled pain. The pharmacy confirmed that the emergency kit was stocked and that authorizations were provided when requested, but there were no calls from the facility on certain dates when the resident reported pain. The resident described experiencing significant pain over a weekend, repeatedly requesting pain medication, and being told to wait due to unavailability of hydromorphone. The resident ultimately required transfer to an acute care hospital for severe pain and hematuria. Staff interviews corroborated the resident's account of delayed pain management and lack of timely medication administration. Facility policy required prompt assessment, medication administration, and physician notification for unrelieved pain, but these procedures were not consistently followed, resulting in the resident suffering from uncontrolled pain.