Failure to Provide Consistent Pain Management and Medication Availability
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with multiple serious medical conditions, including colon cancer, bone cancer, lung cancer, chronic pain syndrome, and pressure ulcers. The resident had an order for a fentanyl transdermal patch to be applied every three days, but the medication was not available on several scheduled dates. Additionally, the resident's pain was not consistently assessed, and staff did not use a pain assessment tool appropriate for his cognitive status as outlined in facility policy. The resident was observed to be in pain, exhibiting nonverbal indicators such as moaning and grimacing, and was unable to verbally express his pain level due to moderate cognitive impairment. Despite having an order for hydromorphone to be administered every six hours as needed for pain, the resident only received this medication once daily. Staff, including the DON and an RN, were unaware that the fentanyl patches were not available on multiple occasions and did not realize the hydromorphone was not being administered as frequently as ordered. The resident's physician was not notified about the missed fentanyl doses or the ongoing pain management issues. As a result, the resident experienced pain, particularly during repositioning for wound care.