Failure to Implement and Monitor Safe Pain Management Interventions
Penalty
Summary
The facility failed to provide safe and appropriate pain management for two residents with significant pain needs. For one resident with chronic pain related to end-stage liver failure, the care plan identified the need for pain management, and the resident was prescribed both oxycodone and a buprenorphine transdermal patch. Multiple severe drug interaction warnings were triggered in the electronic medical record regarding the concurrent use of these medications, but there was no evidence that these warnings were reviewed or discussed with the provider. The resident continued to report increased pain and even exhibited suicidal behaviors due to unmanaged pain, yet the facility did not monitor or revise the pain management interventions as necessary. Another resident, recently admitted with acute and chronic pain following lower extremity bypass surgery and with multiple wounds, had orders for both scheduled and PRN oxycodone. The resident reported not receiving pain medication for extended periods, including a 12-hour gap, due to the medication not being available in the facility. The resident expressed distress and was unable to tolerate dressing changes due to inadequate pain control. Documentation confirmed gaps in pain medication administration, and staff interviews revealed confusion about medication availability and stock management. In both cases, the facility did not ensure that pain management interventions were implemented, monitored, or revised as needed. There was a lack of communication regarding medication interactions and failures in ensuring timely access to prescribed pain medications, resulting in unmanaged pain for both residents.