Failure to Provide Effective Pain Management for Two Residents
Penalty
Summary
The facility failed to provide effective pain management for two residents who required such services. One resident was admitted following a right hip fracture and had a physician order for Oxycodone 30 mg every 6 hours as needed for pain. Upon admission, the resident began experiencing significant pain, but the ordered pain medication was not administered because the nurse on duty did not have access to the emergency medication system, which required two nurses with codes. The resident was instead given acetaminophen, which did not adequately control the pain, and ultimately had to be sent to the emergency room for pain evaluation after repeatedly requesting pain relief and expressing distress. Another resident, admitted with chronic conditions including diabetes and neuropathy, was assessed as being at risk for pain and was prescribed gabapentin 300 mg three times daily for leg pain. The facility failed to administer 14 doses of gabapentin over several days due to a lapse in medication supply, despite staff being aware that the medication was running low and attempting to contact the pharmacy and physician. During this period, the resident did not receive any additional pain medication and reported increased pain, describing a shooting sensation down her leg. No nonpharmacologic interventions were offered to alleviate her discomfort. Interviews with staff and pharmacy representatives confirmed that the emergency medication system contained the necessary medications, but access issues and communication failures prevented timely administration. The facility's processes for medication refills and emergency access were not effectively implemented, resulting in residents experiencing unmanaged pain and missed doses of prescribed medications.