Failure to Manage Post‑Surgical Pain Due to Admission and Pharmacy Process Lapses
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate post‑surgical pain management for a resident admitted after a left total knee replacement. The resident had a history of chronic pain following a motor vehicle injury, morbid obesity, and left knee osteoarthritis, and had been taking Dilaudid chronically prior to surgery. Hospital discharge instructions included multiple pain medications (hydrocodone, hydromorphone/Dilaudid, morphine, and tizanidine) and directions to call the physician for severe uncontrolled pain. The hospital report indicated the resident was admitted specifically for post‑surgical pain control, was cognitively intact, required one‑person assist with a walker, and that controlled substance prescriptions were sent with the discharge packet, with morphine next due at 9:00 PM. Upon arrival at the facility in the early evening, the resident reported already experiencing significant pain. According to the resident, no nurse entered the room until approximately 9:00 PM, at which time an LPN was informed of the resident’s severe pain and request for pain medication. The LPN reportedly stated she was unsure whether any pain medication was available and, despite the resident’s repeated reports of severe pain and that something did not feel right, did not provide any intervention or return with medication. The resident stated that a subsequent call light at about 11:00 PM resulted in contact with an unidentified staff member, but again no intervention occurred, and no nurse assessed or addressed the pain during this period. Around midnight, the resident again used the call light, reporting that the pain and discomfort were no longer tolerable and expressing feelings of being disregarded and not cared for. Another LPN then assessed the resident’s pain and discovered that the controlled substance prescriptions had not been faxed to the pharmacy upon admission, so the ordered pain medications were not available in the facility or in the emergency medication supply. Nursing documentation noted that the prescriptions had to be re‑faxed and a new access code obtained, and confirmed that the resident had not received any prescribed pain medications since admission. During this time, the resident was described as in extreme pain, visibly distressed, tearful, and shaking, and ultimately requested transfer to the emergency department, where she was treated for uncontrolled pain.
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