Failure to Provide Ordered Oxycodone Resulting in Uncontrolled Phantom Pain
Penalty
Summary
The facility failed to provide effective pain management to a cognitively intact resident with all four extremities amputated who experienced phantom pain, neuropathy, and back pain. The resident had an active care plan for pain and physician orders for scheduled and PRN pain medications, including Oxycodone 5 mg twice daily. Medication Administration Records (MARs) for January and February showed that the last documented dose of Oxycodone was given at bedtime on 1/31/26, with the next dose not administered until 2/6/26, resulting in 11 missed doses. During this period, the resident reported being without his pain medication for several days, stated he was in a lot of pain rated 10/10, and described his amputation sites as feeling like they were on fire. He reported that Tylenol was given but did not adequately relieve his pain. Record review and staff interviews revealed documentation and medication availability issues that contributed to the missed doses. The February MAR showed that on multiple days the resident did not receive Oxycodone, and one RN acknowledged signing for a dose on 2/2/26 in error when the medication was not actually available. An LPN reported that when she worked on 2/6/26, the resident did not have Oxycodone, and a prior nurse had documented a code indicating the medication was not given. When the LPN attempted to obtain a dose from the medication dispensing machine, pharmacy access was denied pending management notification, and pharmacy records indicated that 60 Oxycodone tablets had been delivered on 1/17/26, with one card of 30 tablets later reported missing by facility leadership. The facility’s pain management policy required assessment, monitoring, and administration of medications as ordered, but the resident did not receive his prescribed Oxycodone for several days, despite ongoing severe pain and the absence of any documented change in the physician’s order.
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