Failure to Provide Timely and Adequate Pain Management for Severe Fracture
Penalty
Summary
Licensed nurses failed to provide adequate pain management to a resident admitted with a displaced, comminuted fracture of the shaft of the left humerus. The resident was admitted with orders for acetaminophen as the first-line agent and oxycodone 5 mg PO every six hours PRN for severe pain rated 7–10/10, and a care plan directing staff to administer medications per orders, anticipate pain needs, respond immediately to complaints of pain, and follow the pain scale. On the evening of admission, the resident reported pain of 10/10 and received oxycodone at 7:50 p.m., with no further oxycodone doses given that day. On the following day, oxycodone was administered only three times despite documented recurring severe pain levels of 8–9/10, and staff did not recognize or act on the pattern of severe pain returning before the next allowable dose. The resident’s oxycodone administration and effectiveness record from 2/4 through 2/16 showed only temporary relief, with severe pain recurring prior to the next six-hour dosing window. Nursing staff allowed the medication to wear off completely before the next dose instead of contacting the physician to adjust the dosing schedule, resulting in ongoing severe pain. The facility’s pain management policy required that if the pain management program was not effective, the licensed nurse would contact the physician and consult for additional interventions if pain was not relieved by current orders, but this was not done while the resident continued to report severe pain. In addition, when the resident requested additional oxycodone late on the night of admission, the nurse informed the resident that the medication was unavailable and might arrive with later pharmacy deliveries. The nurse offered an ice pack and scheduled acetaminophen; the resident refused acetaminophen, stating it did not work for her, but accepted the ice pack, which did not relieve her pain. Despite the unavailability of the ordered oxycodone and the resident’s ongoing severe pain, the nurse did not immediately attempt to access the E-Kit as required by facility policy for urgent medication needs. The nurse delayed E-Kit access for approximately five hours, during which the resident repeatedly requested oxycodone and remained in unmanaged severe pain until the medication was finally obtained and administered at 7:16 a.m. Interviews with nursing staff and leadership confirmed that the DON, ADON, and physician were not notified of the resident’s unrelieved pain or the pharmacy delays, contrary to facility expectations and policies for pain management and E-Kit use.
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