Failure to Implement Routine Pain Medication Order for Hospice Resident
Penalty
Summary
The facility failed to provide adequate pain management for one resident when a new order for routine morphine sulfate was not implemented for 35 days. The resident, who had diagnoses including palliative care, dementia, mild neurocognitive disorder, history of falling, and legal blindness, was admitted to hospice care and had a physician's order for morphine sulfate to be administered every six hours for pain. Despite the hospice agency faxing and verbally communicating the new order to the facility, the order was not carried out, and the resident continued to receive only PRN pain medication instead of the scheduled dose. Family observations and interviews revealed that the resident was found crying, gasping for breath, and appearing to be in pain during a visit. The family member was informed by facility staff that the resident had missed her pain medication and that the morphine was only available PRN. However, the hospice agency confirmed that the order had been changed to a routine schedule and that the facility had been notified. Documentation from the hospice nurse indicated that the resident was experiencing pain and discomfort, and that the facility nurse had been updated about the new order. Interviews with facility staff, including licensed nurses and the Assistant Director of Nursing, confirmed that there was a miscommunication between the hospice and the facility, resulting in the routine pain medication order not being implemented. The facility's own policies required that prescribed therapies, including those determined appropriate by hospice, be administered as part of the resident's care. The failure to carry out the routine pain medication order led to the resident experiencing unmanaged pain for an extended period.