Failure to Follow Hospice Pain Management Orders Resulting in Resident Harm
Penalty
Summary
Facility staff failed to follow hospice pain management orders for a resident admitted with a terminal illness, resulting in unmanaged pain and harm. The resident had active orders for scheduled and as-needed morphine, with instructions to administer the medication every four hours, including waking the resident if asleep. Despite these orders, there was a significant gap of approximately 18 hours and 39 minutes during which no morphine was administered, as confirmed by a review of the medication administration record and the facility's narcotic log. Documentation inconsistencies were found, with doses recorded on the MAR but not on the narcotic log, and some doses not matching the prescribed amount. Staff interviews revealed that the resident experienced a pain crisis, characterized by symptoms such as tremoring, foaming at the mouth, minimal responsiveness, and moaning. Multiple staff members, including nursing and hospice personnel, acknowledged that the resident's pain was not managed according to the orders, and that the family expressed concern about the lack of pain control. The narcotic log showed crossed-out and rewritten orders, missing RX numbers, and a lack of proper documentation for medication administration. Staff also reported that no action was taken to address the failure in medication administration or to prevent recurrence. Leadership interviews indicated a lack of awareness and oversight regarding the incident. The DON and ADON were not informed of the pain crisis, and upon review, the DON confirmed that procedures for documenting and administering controlled medications were not followed. The DON also acknowledged that pain should have been controlled for a resident receiving hospice services and that the facility's procedures were not adhered to, as evidenced by the discrepancies between the MAR and narcotic log.