Failure to Provide Timely and Effective Pain Management
Penalty
Summary
A resident with a history of chronic and severe back pain, including diagnoses such as chronic pain syndrome, intervertebral disc degeneration, radiculopathy, spinal stenosis, and spondylosis, was admitted to the facility. Upon admission, the resident was alert and oriented, and had physician orders for multiple pain management medications, including gabapentin, Percocet (a narcotic), quetiapine fumarate, and Tylenol. The baseline care plan specified the need for pain medication as prescribed and administration prior to treatments. Despite these orders, only Tylenol was administered when the resident reported severe pain rated at 10 out of 10, and the Tylenol was not effective in managing the pain. The facility's medication administration records and interviews confirmed that the prescribed pain medications, including narcotics and other adjuncts, were available in the facility's Cubex machine at the time of the resident's admission. The process for accessing these medications required nursing staff to call the pharmacy for authorization, which was not done. The pharmacist confirmed that no calls were received for authorization to access the resident's pain medications, and the nurse on duty did not recall attempting to access the Cubex or contacting the pharmacy. As a result, the resident did not receive the prescribed pain management regimen and continued to experience uncontrolled pain. Later that evening, the resident was found on the floor after calling a family member for help due to ongoing pain. Emergency services were called by the family, and the resident was transported to the emergency room, where she reported not receiving her prescribed narcotic medications and only receiving Tylenol. In the ER, the resident was administered morphine, which resulted in improved pain control. Facility policy required assessment and timely administration of pain medication as prescribed, but this was not followed, resulting in a failure to provide safe and appropriate pain management for the resident.