Failure to Ensure Timely Pain Medication Refill and Assessment
Penalty
Summary
A deficiency occurred when the facility failed to provide safe and appropriate pain management for a resident with chronic pain syndrome, quadriplegia, depression, anxiety, left hip osteoarthritis, and opioid dependence. The resident was prescribed a fentanyl transdermal patch to be applied every 72 hours for chronic pain, as well as oxycodone as needed for moderate to severe pain. The facility did not ensure that the required medication order refill form for the fentanyl patch was signed by the physician in a timely manner, resulting in the resident missing two scheduled doses of the fentanyl patch. Documentation shows that the facility ran out of the fentanyl patch, and there was a delay in following up with the physician and pharmacy to secure the necessary authorization and delivery of the medication. During the period when the fentanyl patch was unavailable, the resident reported experiencing severe pain and repeatedly requested the medication from nursing staff. Despite the resident's complaints, documentation in the SBAR Summary for Providers indicated that the resident was not experiencing pain, which contradicted the resident's own statements and the observations of a CNA who noted the resident was always in pain. The resident's care plan required staff to monitor for pain, assess pain characteristics, utilize a pain scale, and medicate as ordered, but these interventions were not consistently implemented during the period when the fentanyl patch was missed. Interviews with facility staff revealed a lack of communication and follow-up regarding the missing medication. Nurses did not endorse the need to follow up on the fentanyl patch order to subsequent shifts, and there was no documented evidence of timely follow-up with the physician or pharmacy after the initial missed dose. The facility's policies required medications to be ordered in advance and pain management to be consistent with professional standards and the resident's care plan, but these procedures were not followed, resulting in unrelieved pain for the resident until the fentanyl patch was reapplied several days later.