Failure to Provide Timely Pain Management for Resident on Hospice
Penalty
Summary
A resident with multiple diagnoses, including pulmonary fibrosis, diabetes, atrial fibrillation, hyperlipidemia, hypertension, and end stage renal disease, experienced ongoing and significant back pain while under hospice care. Despite repeated reports of severe pain and visible signs of discomfort, the resident did not receive timely administration of prescribed pain medication. The resident reported inadequate pain relief and stated that staff could not provide additional medication while waiting for hospice intervention. Pain assessments documented high pain levels, with scores reaching up to 9/10 on several occasions. A new order for Baclofen 10 mg was prescribed by hospice, but the medication was not administered until nearly two days after the order was placed. Staff interviews revealed confusion regarding the availability of the medication, with some staff unaware of its location and others indicating it had not arrived from the pharmacy. The unit manager and LPNs discussed accessing the medication from the emergency drug kit, but delays persisted. The Director of Nursing confirmed that the resident should have received the medication when ordered and acknowledged that staff could have contacted the medical director for an alternative order while waiting for hospice. The facility was unable to provide a medication administration policy when requested.