Failure to Provide Timely Pain Medication
Penalty
Summary
The facility failed to ensure that residents received timely pain medication, resulting in ongoing pain and diminished quality of life for two residents. One resident, admitted for rehabilitation and cognitively intact, reported not receiving pain medication for several hours after admission despite repeated requests. The nurse informed her that the pharmacy did not have her prescription and that there could be a two-hour wait, but the delay extended for several hours. The resident experienced severe pain, rated 10/10, and ultimately called her son for help, who then called 911 to intervene. The pharmacy narcotic log showed that pain medication was retrieved from the emergency medication stock supply several hours after admission. Another resident, admitted for rehabilitation and moderately cognitively impaired, was observed crying and requesting pain medication for leg pain. She reported asking for pain medication since early morning and was told she had run out of medication and that the nurse was waiting for a new prescription to be signed by the provider. The medication administration record indicated a significant gap between doses, with the resident waiting nearly 10 hours for pain relief. The nurse stated she was waiting for the provider to sign the order but did not attempt to contact the provider directly, assuming the provider was busy. The provider later confirmed she was available and had not been notified of the need for additional pain medication. Interviews with facility staff revealed that there was a system in place to access emergency medication stock, which should have allowed for timely administration of pain medication within 15 minutes. However, this process was not followed, resulting in prolonged pain for both residents. Both residents described experiencing severe physical and psychological distress due to the delays in receiving pain medication.