Failure to Administer Physician-Ordered Pain Medication for Severe Pain
Penalty
Summary
Licensed nursing staff failed to administer physician-ordered pain medication to a resident who was admitted following digestive system surgery and was experiencing moderate to severe pain. The resident's care plan specified that pain should be relieved to a tolerable level, with interventions including administering treatment as ordered, assessing pain every shift, and notifying the physician if pain became unmanageable. Despite these directives, the resident was only given acetaminophen, which was ordered for mild pain, even as her pain levels increased to moderate and severe levels as documented in the medication administration record (MAR). The physician had ordered morphine sulfate for moderate to severe pain, but the resident did not receive any doses of this medication during the period when her pain was documented as worsening. Progress notes indicated that acetaminophen provided minimal relief and that the resident reported nausea from acetaminophen. The MAR and interviews confirmed that the morphine order was not carried out, and there was no documentation that the physician was notified about the resident's escalating pain or the ineffectiveness of the prescribed pain management. The facility pharmacist confirmed that a clarification request was sent to the physician due to a listed morphine allergy, but there was no follow-up from facility staff or the physician, and no documentation of any adverse effects when morphine was eventually administered after the resident's return from hospitalization. Interviews with the resident revealed that she repeatedly requested additional pain medication and felt her pain was not believed or addressed by nursing staff. The DON confirmed that pain assessments and appropriate medication administration were not consistently documented or performed according to the care plan and facility policy. The facility's policies required timely administration of medications as ordered and immediate contact with the prescriber if pain was not controlled, but these procedures were not followed, resulting in the resident experiencing ongoing, severe pain.