Failure to Provide Timely Pain Management for Resident with Severe Pain
Penalty
Summary
Facility staff failed to provide appropriate pain management for a resident with a history of fractures and recent surgical wounds on both knees. The resident was observed multiple times reporting knee pain and stated that while pain was usually managed, there were instances of severe pain that were not relieved by medication. On one occasion, the resident reported experiencing 10/10 pain in both knees and requested as-needed Oxycodone, but was informed by nursing staff that it was no longer on her medication list. The nurse documented the request and updated the MD Communication Book but did not provide immediate intervention or contact the on-call physician for alternative pain relief. A review of the resident's clinical records showed that an order for as-needed Oxycodone was not reinstated until several hours later, and there was no evidence that the attending nurse practitioner or physician was made aware of or addressed the severe pain episode at the time it occurred. Interviews with facility staff confirmed that the appropriate protocol would have been to contact the on-call physician for immediate pain management, especially for a report of 10/10 pain. The facility's pain management policy required a pain assessment whenever a patient experienced unusual pain, but there was no documentation of such an assessment or timely intervention in this case.