Failure to Provide Adequate Pain Management Due to Medication Order Error
Penalty
Summary
A resident with diagnoses including left knee osteomyelitis and a sacral pressure ulcer was admitted to the facility following a hospital stay, with a pain management plan that included hydromorphone 4 mg every 4 hours for moderate to severe pain and an additional dose for breakthrough pain. Upon admission, physician orders were written for hydromorphone 4 mg every 4 hours PRN and another for every 24 hours PRN. However, the order for every 4 hours PRN was discontinued the following day, leaving only the once-daily PRN order in place. The resident subsequently experienced severe pain, requested additional pain medication, and was informed by staff that the medication was not due. The resident then called 911 and was transferred to the hospital for pain management. Record review and staff interviews revealed that the discontinuation of the every 4 hours PRN hydromorphone order was done in error, and nursing staff were unaware of the reason for the discontinuation. The nurse did not contact the on-call provider to address the resident's pain prior to the resident's transfer to the hospital. The Nurse Practitioner confirmed that both orders should have been in place and that timely administration of the medication could have better controlled the resident's pain. The Assistant Director of Nursing Services acknowledged the error in discontinuing the order and was unaware if the nurse attempted to contact the provider before the resident left the facility.