Failure to Provide Prescribed Pain Management
Penalty
Summary
The facility failed to provide prescribed pain management for a resident admitted for rehabilitation following multiple fractures sustained in a motor vehicle accident. The resident had orders for both extended-release and immediate-release morphine to manage moderate to severe pain. Over a weekend, the facility ran out of the resident's prescribed morphine, and no additional medication was available in the medication cart or back-up supply. The resident consistently requested pain medication as ordered, but staff discovered there were no refills remaining and no in-house provider was available to write a new prescription. Attempts to substitute with oxycodone were unsuccessful due to insufficient supply, and the pharmacy could not deliver the required medication until after the weekend. As a result, the resident experienced unrelieved, severe pain, with documented pain levels frequently at 10 out of 10. The resident was transferred to the emergency department for pain management due to the facility's inability to provide the prescribed medication. Upon return, the resident continued to report high pain levels and exhibited signs of distress, agitation, and anxiety related to the uncertainty of receiving pain medication. The resident expressed dissatisfaction and concern for his safety due to the lack of pain control. Interviews with facility staff, including an LPN, the Assistant Director of Nursing, and the Director of Nursing, confirmed that the medication should have been reordered before supplies were depleted. Facility policy required each shift to maintain adequate medication supplies and reorder as needed, but this process was not followed, resulting in the resident's pain going untreated and necessitating transfer to the hospital for pain relief.