Failure to Provide Scheduled Pain Medication Resulting in Uncontrolled Pain and Hospital Transfer
Penalty
Summary
A deficiency occurred when a resident with chronic pain and multiple medical conditions, including spinal cord injury and chronic pain syndrome, did not receive scheduled Morphine Sulfate as ordered for pain management. The resident's physician had prescribed Morphine 30 mg, two tablets by mouth every eight hours, but the facility ran out of this medication. The last documented dose was administered in the afternoon, after which three consecutive scheduled doses were missed. During this period, the resident experienced severe pain, including a headache and nausea, and reported that alternative pain medications such as oxycodone-acetaminophen and Tylenol were ineffective. The breakdown in medication administration was due to failures in the facility's refill and communication processes. Nursing staff identified that the resident was running low on Morphine and faxed refill requests to the physician. Although the physician indicated that a hard copy prescription was sent to the pharmacy, there was no confirmation that the pharmacy received the request, and the medication was not delivered. Nursing staff did not follow up with the pharmacy as instructed, nor did they escalate the issue to the Unit Manager, DON, or Administrator in a timely manner. The Unit Manager and other staff were aware that the resident was out of Morphine but did not take further action to resolve the situation or notify higher-level staff. As a result, the resident missed three consecutive doses of scheduled Morphine, experienced uncontrolled pain, and ultimately required transfer to the emergency room for severe headache, nausea, and ineffective pain control. Interviews with staff and review of documentation confirmed that the facility failed to ensure the resident received pain medication as ordered, and that communication and follow-up procedures were not properly executed, directly resulting in actual harm to the resident.