Failure to Provide Consistent Pain Management Due to Medication Access and Documentation Issues
Penalty
Summary
The facility failed to provide adequate pain management for three residents who were prescribed opioid pain medications. Multiple instances were documented where residents did not receive their scheduled opioid medications due to issues such as pharmacy delays, lack of access to the automated medication dispensing machine, and insufficient staff knowledge or training regarding medication refills and emergency access procedures. In several cases, the medication administration record (MAR) indicated missed doses coded as 'other/see nurses note,' but corresponding nursing notes were often missing or incomplete. Residents reported experiencing increased pain, withdrawal symptoms, and anxiety as a result of missed doses, and staff interviews revealed confusion about protocols for obtaining and administering controlled substances when regular supplies were depleted or inaccessible. For one resident with a history of spinal stenosis, diabetic neuropathy, and chronic pain, there were repeated missed doses of oxycodone due to pharmacy delivery delays and inability to access the emergency drug kit, especially when only agency nurses were present who lacked the necessary access. The resident described experiencing withdrawal symptoms and increased anxiety during these periods. Staff interviews confirmed that agency nurses often did not know the refill process or lacked access to the emergency supply, and documentation of physician notification or alternative pain management was inconsistent or absent. The facility's own protocols required timely preparation of prescriptions and notification of supervisors or the DON when medications were unavailable, but these steps were not reliably followed. Two other residents with chronic pain conditions also experienced missed or held doses of opioid pain medications, with documentation gaps and lack of clear communication with physicians or pharmacy. In some cases, medications were held due to resident refusal or drowsiness, but required documentation was not completed. Staff interviews indicated a lack of orientation and education for agency nurses, and some staff were unaware of emergency access procedures or on-call contacts. The facility's failure to ensure consistent access to pain medications, proper documentation, and adherence to pain management protocols resulted in residents not receiving necessary pain relief as ordered.