Failure to Provide Timely and Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for two residents who required such services, resulting in harm. One resident was admitted following hospitalization for multiple fractures and had a history of pain, anxiety, and depression. Upon admission, this resident did not receive prescribed pain medications due to issues with obtaining valid prescriptions from the hospital and delays in entering the resident into the pharmacy system. The resident experienced severe, uncontrolled pain and was ultimately sent back to the emergency room for pain management. Documentation showed that the resident's pain was not adequately addressed upon arrival, and staff were unable to access the facility's emergency medication supply due to the lack of valid prescriptions and authorization codes from the pharmacy. Another resident was admitted with a fracture and had orders for multiple pain medications, including Roxicodone, Tramadol, and acetaminophen. Despite these orders, the resident did not receive the prescribed narcotic pain medications because the scripts were not received by the pharmacy in a timely manner. Staff administered acetaminophen for pain, but there was inconsistent documentation of pain assessments and medication administration. The resident reported severe pain and repeatedly stated that prescribed pain medications were not available. Staff interviews revealed confusion about the process for obtaining and administering narcotic medications from the emergency supply, and the resident's pain was not effectively managed until the correct medications were finally delivered and administered. In both cases, the facility's failure to ensure timely receipt and administration of prescribed pain medications, as well as inadequate communication and documentation, led to residents experiencing unnecessary pain. The facility's own pain management policy required prompt evaluation and intervention for pain, but these procedures were not followed, resulting in harm to the residents involved.