Based on review of select facility policies, clinical record review, and staff and family interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered pain medications and pain management for one of one resident reviewed (Resident 264).
The facility policy entitled, "Pain Management," last reviewed on January 7, 2020, revealed that each resident who experiences pain or discomfort shall receive care to manage the pain or discomfort. The level of the resident's pain level will be determined and documented. Residents experiencing unrelieved pain will have follow-up with the physician.
The policy did not address "as needed" (PRN) pain medications and how they are administered according to physician orders following the pain scale parameters.
Clinical record review of Resident 264's diagnostic profile revealed that the resident had malignant (spreading cancer) pancreatic (pancreas, a gland located behind the stomach and in front of the spine) cancer.
Interview with a family member of Resident 264 on January 7, 2020, at 12:18 PM revealed that there was a breakdown with pain medications between shifts and that the resident did not have enough pain medication the first night of admission.
Clinical record review of Resident 264's physician orders revealed the following PRN medications for pain on January 2 and 3, 2020:
Acetaminophen Tablet 325 mg (milligram), administer two tablets by mouth every four hours PRN mild pain or temperature greater than 100 degrees Fahrenheit
Oxycodone (narcotic medication for moderate to severe pain) 5 mg tablet by mouth every four hours as need for pain related to malignant neoplasm (cancer growth) of pancreas
Morphine Sulfate Solution (narcotic medication for severe pain) 20 milligrams/milliliter (mg/ml), administer 5 mg/ 0.25 ml every two hours by mouth as needed for pain
Nursing documentation for Resident 264 dated January 2, 2020, at 9:58 PM revealed the resident was admitted to the facility at 5:00 PM. The resident arrived with a Fentanyl Patch (a narcotic pain medication absorbed through the skin from over a period of 72 hours). The resident complained of pain of a 10 out of 10 (pain scale of zero is no pain, pain scale of 10 is severe pain). The pain was treated with acetaminophen and roxanol (morphine sulfate solution).
Review of Resident 264's MAR (Medication administration record) for January 2, 2020 revealed that PRN Morphine Sulfate Solution, 5mg/0.25 ml by mouth was administered at 8:45 PM for a pain level of 10 and it was effective for pain relief.
Review of Resident 264's MAR for January 3, 2020, revealed that PRN Oxycodone 5 mg was administered at 8:15 AM for a pain level of 10. This was documented as ineffective pain relief. Staff administered PRN Morphine Sulfate 5mg/0.25 ml at 9:49 AM for a pain level of eight, which was documented as effective. There was no documentation to indicate that a PRN pain medication was attempted prior to the pain level going to a level of 10 at 8:15 AM. There were no parameters listed in the physician orders indicating when to administer the Morphine Sulfate versus the Oxycodone.
The surveyor reviewed the above findings with the Director of Nursing for Resident 264 on January 9, 2020, at 11:00 AM.
28 Pa. Code 211.10(a)(c) Resident care policies
28 Pa. Code 211.10(d) Resident care policies
Previously cited 2/3/19
28 Pa. Code 211.12 (d)(1)(5) Nursing services
Previously cited 2/3/19