Failure to Provide Timely Pain Medication Results in Unmanaged Pain and Hospitalization
Penalty
Summary
The facility failed to provide appropriate pain management for two residents who required such services, resulting in significant lapses in care. One resident, who was cognitively intact and had a history of heart and kidney disease, was admitted to hospice and had physician orders for scheduled and PRN morphine for pain and shortness of breath. The facility ran out of the resident's prescribed morphine, and staff did not reorder the medication in a timely manner. As a result, the resident went several days without receiving the narcotic pain medication, experienced unmanaged pain, and developed symptoms consistent with opioid withdrawal, including nausea, vomiting, diarrhea, cold sweats, and elevated blood pressure. The resident was ultimately transferred to the hospital for evaluation and treatment. Documentation confirmed that seven doses of morphine were missed due to the medication being unavailable or not administered, and staff interviews revealed ongoing issues with medication reordering processes and communication with the on-call provider. Another resident with polyosteoarthritis had a physician order for Lyrica twice daily for pain management. The facility ran out of Lyrica, and the resident did not receive the medication for several doses over multiple days. During this period, the resident's pain levels fluctuated from 0/10 to 10/10, and non-pharmacological interventions were attempted but were not effective. Staff acknowledged that there was no designated person responsible for reordering medications, leading to frequent medication shortages, especially over weekends. The resident reported experiencing constant pain and stated that running out of pain medication was a recurring issue. In both cases, the facility's failure to maintain adequate medication supplies and ensure timely reordering directly resulted in residents experiencing unmanaged pain and, in one case, opioid withdrawal and hospitalization. Staff interviews and documentation confirmed that the medication management system was ineffective, with lapses in communication and follow-through on medication orders.