Failure to Provide Timely and Effective Pain Management
Penalty
Summary
A resident with a history of low back pain, venous thrombosis, embolism, post-traumatic stress syndrome, and bilateral lower extremity burns reported significant pain during the night and requested pain medication. The resident informed a CNA of her pain, which was rated as 8 out of 10, but the night shift nurse was unable to provide the prescribed pain medication, stating it was not available and would be delivered in the morning. The nurse did not retrieve the medication from the convenience box, as was expected by facility policy, and did not assess or document the resident's pain level at that time. Facility records showed that the resident had an active order for oxycodone-acetaminophen to be administered every four hours as needed for pain, and the care plan included interventions to administer pain medication as ordered. The facility's pain management policy required pain to be assessed at least once every shift and documented using appropriate pain scales. Despite these policies and orders, the resident's pain was not effectively monitored or treated during the incident, resulting in a failure to provide safe and appropriate pain management.