Failure to Timely Administer Pain Medication Due to Staff Communication Breakdown
Penalty
Summary
A resident with diagnoses including right trochanteric bursitis, type 2 diabetes, and chronic pain syndrome was admitted to the facility and had physician orders for pain management, including Hydrocodone-acetaminophen for moderate pain and Oxycodone for severe pain. On a specific night, the resident reported experiencing severe pain around 2 A.M. and requested pain medication multiple times but did not receive any at that time. The electronic Medication Administration Record confirmed that no pain medication was administered during the period in question. Interviews with nursing staff revealed that the nurse assigned to the resident was on break and did not hand over the medication cart keys, preventing another nurse from accessing and administering the medication. Additionally, the nurse who was aware of the resident's pain request forgot to inform the assigned medication nurse upon their return. As a result, the resident's pain was not addressed in a timely manner, and the opportunity to provide pain relief was missed during the overnight hours.