Failure to Provide Timely Pain Management Due to Medication Access Issues
Penalty
Summary
Facility staff failed to provide safe and appropriate pain management for a resident with chronic kidney disease, low blood pressure, and heart disease, who required pain control, particularly before dialysis treatments. The resident had physician orders for both scheduled pain assessments and as-needed (PRN) analgesics, including acetaminophen and tramadol. Despite these orders, staff did not administer the prescribed tramadol prior to dialysis, even when the resident reported severe pain rated at 8 out of 10. Instead, only acetaminophen was given, which the resident stated was less effective. Documentation showed that staff did not record the reasons for not administering tramadol, nor did they notify the physician or management about the inability to access the medication. Multiple interviews revealed that several LPNs and a Certified Medication Tech (CMT) were unable to access the medication dispensing system or the electronic medical records (EMR) due to lack of system access, especially for staff who did not regularly work at the facility. As a result, they could not administer PRN pain medications, including tramadol, as ordered. Staff were aware of the resident's pain and the usual practice of administering tramadol before dialysis, but were unable to fulfill this due to access issues. The resident repeatedly reported severe pain and distress, both verbally and through nonverbal cues, over the course of two days. Facility leadership, including the Social Services Director, Medical Director, and Administrator, confirmed that nurses should have had access to the medication dispensing system prior to starting their shifts. However, the Administrator was not aware of the access issues until after the events occurred. Staff interviews indicated that, in the absence of access, they did not escalate the issue to management or the physician in a timely manner, nor did they document the lack of access or the resident's ongoing pain in the medical record. This resulted in the resident not receiving prescribed pain management consistent with professional standards of practice and the resident's care plan.