Failure to Provide Effective Pain Management and Timely Follow-Up
Penalty
Summary
A resident with a history of secondary malignant neoplasm of digestive organs, acute kidney failure, and anxiety disorder experienced increasing abdominal pain and swelling over several days. Despite repeated complaints of pain, visible abdominal swelling, and inability to reposition due to discomfort, the resident reported that her pain was not being adequately controlled and felt that nothing was being done to address her concerns. The resident expressed a desire to see her specialist, and her pain was frequently rated at 6/10, escalating to 10/10 on the day of transfer to the emergency department. Review of the resident's electronic medical record showed multiple administrations of PRN oxycodone and acetaminophen for pain, as well as lorazepam for anxiety. The resident was sent to the emergency department for evaluation of increased abdominal pain, where she received additional pain and anxiety medications. Upon return to the facility, discharge instructions included a follow-up appointment with her primary care physician within two to four days; however, there was no documentation that this follow-up was scheduled or completed, nor was there evidence of follow-up care after the emergency department visit. Progress notes and staff interviews indicated ongoing concerns about the resident's pain, with staff documenting frequent requests for pain medication and persistent high pain ratings. Despite these reports and visible symptoms, there was a lack of documented provider consultation or escalation of care in response to uncontrolled pain, as required by the facility's pain management policy. The deficiency was identified due to the failure to provide effective and appropriate pain management and to ensure timely follow-up and provider involvement for a resident with significant pain and complex medical needs.