F0697

G

Failure to Provide Effective Post‑Operative Pain Management for a Surgical Resident

Dubuque, Iowa Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide effective pain management, including administration of ordered analgesics and related medications, for a post‑operative resident with severe spinal surgery pain. The resident had undergone complex lumbar fusion surgery with hardware placement and was admitted with orders from the neurosurgeon for a multimodal pain regimen including oxycodone (5 mg for moderate pain and 10 mg for severe pain every 4 hours PRN), methocarbamol, Tylenol, a Lidoderm patch, and later Lyrica. The MDS documented almost constant pain, worst pain at 8/10 over the prior five days, frequent impact on sleep, and occasional impact on daily function. The resident’s care plan directed staff to administer pain medications per physician orders, evaluate pain and efficacy, monitor aggravating factors, and notify the MD if pain relief was inadequate or if interventions were unsuccessful.

Despite these orders and care plan directives, facility staff and the NP altered and restricted the resident’s pain regimen without coordinating with the neurosurgeon and did not consistently administer pain medications as ordered. The NP discontinued the oxycodone 10 mg order and substituted tramadol 50 mg every 6 hours PRN, then intermittently re‑ordered and discontinued oxycodone 10 mg, ultimately reducing the resident to oxycodone 5 mg every 4 hours PRN plus tramadol. The neurosurgeon’s office documented that the resident reported difficulty obtaining pain medications as ordered and that staff at the facility did not want to administer them; the neurosurgeon’s office instructed the facility to “give meds as ordered” and noted the resident’s severe, expected post‑surgical pain. The facility did not contact the neurosurgeon’s office about reducing the pain medication, even though that office was the physician of record for pain management.

Nursing staff actions further contributed to inadequate pain control. One RN refused to give pain medication even a few minutes early, including before a scheduled neurosurgical follow‑up, resulting in the resident traveling and waiting for transport without analgesia despite reporting significant pain. A night‑shift LPN repeatedly delayed or withheld ordered narcotic analgesics, told the resident it was “too soon” or that he could not be in that much pain, and did not promptly notify a provider when the resident reported severe, unrelieved pain at 10/10 and had low blood pressure. On the night before the resident called 911, the LPN acknowledged the resident’s reports of severe pain, low BP readings, and his requests to go to the hospital, but only administered tramadol once at 3:15 a.m. and left at least one voicemail without a message before finally speaking with the on‑call provider after the resident had already called 911. The resident, family member, neurosurgeon’s office nurse, and another night‑shift RN and CNA all described frequent severe pain, difficulty obtaining ordered pain medications, and the resident being awake much of the night due to pain, culminating in the resident calling 911 for transfer to the hospital for pain management.

The facility’s own pain management policy required staff to advocate for pain management, avoid labeling and judging residents, treat pain early, and report pain scores of 5 or greater twice in 7 days or any single episode of 10/10 to a medical practitioner for possible treatment adjustment and IDT review. The resident’s MAR showed frequent pain scores of 7–10/10 and around‑the‑clock use of PRN opioids, yet staff did not consistently escalate concerns or adjust treatment in collaboration with the neurosurgeon. The DON later acknowledged that the night‑shift LPN believed the resident was “drug‑seeking” and therefore did not feel obligated to contact the MD about increased pain, and that it was unacceptable not to notify the physician when pain increased or when analgesics were withheld due to low BP. The NP also stated that staff should report increased or unrelieved pain and notify the provider when medications are withheld for altered vital signs unless parameters are specified. These documented inactions and deviations from orders and policy resulted in the resident experiencing ongoing severe pain, sleep disturbance, and ultimately calling 911 to obtain hospital‑based pain control.

The resident’s experience was corroborated by multiple interviews. The resident reported having a very difficult time getting pain medication as ordered, described severe post‑surgical pain that was only partially relieved by oxycodone 10 mg, and recounted that a night‑shift nurse ignored or minimized his requests, told him it was too soon for medication, and delayed contacting the physician when his pain remained at 10/10 for several hours. The resident’s family member stated staff were not good about giving pain medication as prescribed, that the resident had to constantly ask and wait, and that this worsened his pain and anxiety. A CNA described the resident being up most of the night due to pain and repeatedly asking to go to the hospital. Another night‑shift RN confirmed the resident’s frequent pain scores of 7–10/10, non‑verbal signs of pain, and need for oxycodone 10 mg about every 4 hours, and stated he did not believe the resident was drug‑seeking. EMS and ED records documented the resident’s 10/10 back pain on arrival, the need for multiple IV and oral medications including strong opioids and non‑opioid agents, and that the resident had called 911 from the facility for pain management.

The facility’s Administrator was initially unsure whether the resident’s pain had been addressed by the IDT as required by policy and later stated that the IDT recommended assessment by their provider, without providing a date. The facility’s pain policy also required reporting of significant pain episodes and IDT review, but the record did not show timely, effective IDT intervention in response to the resident’s persistent high pain scores and repeated complaints. Overall, the documented actions and inactions by the NP and nursing staff, including altering the neurosurgeon’s pain regimen without consultation, rigid timing and withholding of ordered analgesics, failure to promptly notify providers of severe, unrelieved pain and low BP, and failure to follow the facility’s own pain management policy, led to the resident experiencing inadequately managed post‑operative pain, sleep disturbance, and the need to seek emergency care by calling 911.