Failure to Provide Timely Pain Medication Administration
Penalty
Summary
The facility failed to ensure that a resident with chronic pain received pain medication as ordered, resulting in multiple instances where the resident experienced severe pain due to unavailability of prescribed oxycodone. The resident, who had diagnoses including discitis, chronic pain, post-polio syndrome, and muscle weakness, was prescribed oxycodone 20 mg four times daily. Despite this, there were repeated occasions documented in the Medication Administration Record (eMAR) and progress notes where the medication was not available at the scheduled times, and the resident went without the ordered pain relief for hours or until the next day. Staff often documented that the medication was on order, awaiting delivery, or unavailable, and offered alternative interventions such as Tylenol or ibuprofen, which the resident refused due to lack of efficacy in the past. Interviews with nursing staff and facility leadership revealed that medication reordering processes were inconsistent and often delayed. Staff reported challenges with the pharmacy, including restrictions on early refills and requirements for new prescriptions with each order, which led to delays in obtaining the medication. The emergency kit (e-kit) did not always contain the correct dosage, necessitating additional physician orders and further delays. The resident was not consistently informed in advance about medication shortages and was only notified at the time the medication was due, causing distress and uncertainty about when pain relief would be available. As a result of these failures, the resident experienced multiple episodes of severe pain, leading to repeated calls to emergency medical services and hospital transfers to obtain pain relief. Documentation shows that the resident expressed frustration and distress over the unpredictability of pain management and the lack of timely communication from staff. The facility's pain management policy required timely assessment and administration of pain medication, but these procedures were not followed, directly contributing to the resident's unmanaged pain and repeated hospitalizations.