Failure to Provide Prescribed Pain Medication Resulting in Unmanaged Pain
Penalty
Summary
A deficiency occurred when a resident with a history of peripheral vascular disease, diabetes mellitus, and an above-knee amputation was not provided with their prescribed pain medication, Oxycontin, for several consecutive days. The resident's care plan included scheduled opioid pain management, and clinical documentation showed ongoing severe pain, including phantom limb pain and anxiety related to pain. Despite repeated documentation of pain and requests for medication, the facility failed to ensure the availability and administration of the prescribed pain medication from 8/13/25 to 8/18/25. During this period, medication administration records repeatedly noted that the pain medication was not available, and staff were awaiting a prescription from the primary care provider. The resident reported severe pain, rated as 10/10, and expressed distress and anger over the lack of medication. Staff documented communication attempts with the primary care provider and the orthopedic surgeon, but no new orders were obtained, and the medication remained unavailable. The resident's pain was not managed as required by the care plan and facility protocol, which instructed immediate contact with the prescriber if pain was not controlled. As a result of the unaddressed pain, the resident was sent to the emergency department on two occasions for pain management. Emergency department records confirmed that the resident sought care due to the lack of pain medication at the facility and received the necessary medication at the hospital. The resident returned to the facility with medication, but the issue persisted until the prescription was finally filled. Interviews with staff and the resident confirmed the ongoing pain and lack of medication during this period.