Failure to Administer Pain Medication as Ordered
Penalty
Summary
A resident with a history of severe pain due to neuropathy, recent orthopedic and heel surgery, and multiple pressure ulcers did not receive pain medication as ordered by the physician. Upon admission, the resident was assessed as having frequent, severe pain, and had orders for both acetaminophen and oxycodone to be administered as needed for pain management. Despite these orders, documentation shows that the resident did not receive acetaminophen from the time of arrival through several days, and there were inconsistencies in the administration of oxycodone, with gaps in documentation and missed doses. On one occasion, the resident reported pain at a level of 10/10, which was described as their baseline, and repeatedly requested pain medication throughout the night. Certified Nurse Aides (CNAs) observed and reported the resident crying, yelling, and expressing severe pain multiple times to the agency charge nurse. The agency nurse did not administer the ordered pain medication, citing lack of access to the automated drug dispensing machine (Pixus), and did not notify facility leadership or the physician about the inability to provide the medication. The nurse also refused to provide care, stating their shift had ended, and left the facility before the replacement nurse arrived, leaving the resident without pain relief for an extended period. Interviews with staff confirmed that agency nurses did not have access to the Pixus and were expected to request assistance from facility nurses to obtain medications. However, this process failed, resulting in the resident not receiving pain medication as ordered. The DON and Administrator were not made aware of the resident's pain or the medication access issue until the following morning, and the resident's physician was not notified of the problem. The facility's pain management policy required systematic recognition, evaluation, and treatment of pain, but these procedures were not followed, leading to the resident experiencing unmanaged severe pain.