Failure to Provide Consistent Pain Management for Resident with Severe Pain
Penalty
Summary
A resident with a diagnosis of pancreatic adenocarcinoma and other serious medical conditions was admitted to the facility with physician orders for pain management, including Dilaudid and acetaminophen. Despite these orders, staff failed to consistently administer the prescribed pain medications as ordered. Documentation revealed that the resident experienced severe pain, with pain levels reaching up to 10 on a 0-10 scale, and there were multiple instances where pain medications were not available or not given as ordered. The resident's medication administration record showed significant delays in receiving both Dilaudid and Tramadol, and there were periods where the resident received only acetaminophen, which was documented as ineffective for their pain level. The facility's records indicated that there were issues with obtaining the necessary prescriptions from the physician and with the timely delivery of medications from the pharmacy. The pharmacy did not receive a written prescription for Dilaudid until several days after the resident's admission, resulting in the medication not being available in the facility. Staff interviews confirmed that some nurses did not have access to the Pyxis medication dispensing system due to their employment status, and there was confusion about the process for obtaining medications when they were not immediately available. Documentation also showed that alternative pain medications were not always administered promptly, and there was a lack of consistent pain assessment and follow-up after medication administration. Throughout the resident's stay, there were repeated failures to document pain levels, reasons for holding medications, and the effectiveness of pain interventions. Nursing notes and medication administration records frequently lacked explanations for missed or delayed doses, and there was insufficient communication with the physician regarding the resident's unmanaged pain. The resident continued to experience high levels of pain until pain management was eventually adjusted, but the initial failure to provide timely and appropriate pain relief resulted in significant harm and increased the likelihood of a painful death.
Removal Plan
- Educate licensed nurses on the facility's policy for Pain Management
- Educate on actions to take when physician ordered medications are unavailable for administration
- Use Pyxis for immediate availability of narcotics on admission
- Document pain scores before and after pain medication administration and document effectiveness for PRN medications used for pain
- Educate that if any resident is experiencing unmanaged pain, the nurse will call the physician for alternate orders
- Provide resident with alternate physician ordered medications to ensure relief until the prescribed narcotic is available