Failure to Provide Timely PRN Pain Medication for Resident with Chronic Pain
Penalty
Summary
A deficiency occurred when staff failed to provide appropriate pain management for a resident with chronic pain syndrome and multiple serious diagnoses, including malignant neoplasm of the larynx, osteomyelitis, fibromyalgia, and a bowel rupture with colostomy. The resident was cognitively intact, independent in most activities of daily living, and under hospice care. Physician orders specified that oxycodone 10 mg tablets were to be administered every three hours as needed for pain. However, documentation revealed that the resident did not receive her PRN pain medication for nearly 24 hours, despite multiple requests and reports of severe pain. Medical record review and interviews indicated that the facility ran out of the prescribed oxycodone, and staff did not notify hospice or obtain an emergency supply in a timely manner. The controlled drug record showed the medication was depleted, and the resident reported to both staff and hospice that she was in significant pain and unable to receive her medication. The hospice nurse confirmed being notified by the resident via text message that the medication was unavailable, and subsequently arranged for an emergency supply, which was not administered until the following day. There was no documentation that the hospice nurse was notified by facility staff when the medication first became unavailable. Facility policy required that medication administration be based on resident need and that medication errors be documented and reported. The pain management policy also required immediate notification of the provider if pain was not adequately controlled. Despite these policies, staff did not ensure the resident received her ordered pain medication, did not document the resident's repeated requests for pain relief, and failed to communicate the medication shortage to hospice in a timely manner. This resulted in actual harm to the resident, who experienced severe, uncontrolled pain for an extended period.