Failure to Provide Timely Pain Management for Post-Surgical Residents
Penalty
Summary
The facility failed to provide timely and appropriate pain management for two residents who required such services following recent surgeries. One resident, admitted after a total hip replacement, reported severe pain (8 out of 10) upon arrival and did not receive any pain medication until nearly six hours later, despite having physician orders for multiple pain medications. The resident had to leave their room to seek assistance, and staff informed them that pain medications could not be given due to a lack of written scripts, even though the medications were available in the facility's emergency kit (Ekit). Documentation confirmed that the resident's pain was not addressed promptly, and the necessary medications were accessible but not administered as ordered. Another resident, admitted for skilled therapy after spinal surgery, also experienced severe, unrelieved pain upon admission, with a pain score of 10 out of 10 and associated symptoms such as elevated heart rate and inability to remain still. Despite having standing orders for morphine and acetaminophen, the resident did not receive any pain medication during their stay. The clinical record and nurse notes indicated that the resident became verbally angry about the lack of pain control and ultimately discharged against medical advice to seek pain relief at an emergency room. The facility's Ekit contained the ordered morphine, but it was not provided, and there was no evidence of any pharmaceutical or non-pharmaceutical interventions being implemented. Interviews with facility staff revealed a lack of awareness regarding the availability of pain medications in the Ekit and a failure to notify providers of uncontrolled pain or implement alternative pain management strategies. The documentation and staff statements confirmed that both residents experienced significant delays or omissions in pain management, despite the presence of physician orders and available medications.