Medical and nursing pain management receives significant attention because of the opioid crisis. Pharmacy and medical experts are constantly looking for less-addictive drugs that may achieve similar pain relief for patients.
In my practice as a Houston, Texas medical malpractice lawyer, I’ve handled numerous hospital and nursing home (skilled nursing facility or SNF) cases where another aspect of pain management is the issue. This problem is overmedication—not in terms of causing an addiction to painkillers, but rather in giving patients so many pain medications that it kills them. Sometimes investigations have revealed that nurses gave excessive painkillers just to keep patients quiet!
A few cases immediately come to mind, both involving healthy women in their 60s and 70s who were admitted to a facility after sudden injuries.
In one case, a very active lady in her 60s injured her back in a car wreck and required surgery. She was discharged from the hospital to a skilled nursing facility. They didn’t plan for her to be there for long before she would go home. Her attending physician at the SNF was a hospitalist. Upon admission, he made phone orders for medications, including narcotic painkillers.
Within a few days, she died—all before the hospitalist had ever seen her in person or even met her. The autopsy showed that she died from polypharmacy (multiple drug) toxicity. In other words, she had been overdosed by her doctor and nurses.
In a second case, a lady in her early 70s was at church with her family when she tripped and fell. She fractured a vertebra in her neck during the fall and needed surgery. After surgery, while she was still in the hospital, the surgeon and nursing staff controlled her pain with the narcotic opioid medication Dilaudid, which is also known to cause nausea. They gave her too much pain medication and it put her to sleep.
When painkillers put a patient to sleep, they also cause loss of airway control. She vomited while she was asleep and aspirated (breathed in) the vomit. This caused a bad case of pneumonia, which ultimately took her life.
What’s expected of doctors and nurses when it comes to painkillers?
Doctors are required to be knowledgeable about different pain medications and the neurological pathways that they use to work. They should tailor their painkiller prescriptions to individual patient needs, selecting the least addictive medications and lowest dosages that will achieve the desired pain relief.
While physicians are the ones who prescribe pain medications, the responsibility doesn’t end there. The Texas Board of Nursing rules require registered nurses to understand the “rationale and effects” for all medications that they administer. The rationale is the reason the medication is being given. The effects are the result that’s expected after the medication is given.
To understand the effects of medication, nurses must perform comprehensive assessments before the pain medication is given, to establish a baseline. They must reassess the patient and document the effects of the medication at an appropriate time interval after the pain medication is given.
Pain management is a multidisciplinary responsibility shared by doctors and nurses. Careful documentation, appropriate questioning of orders, and good communication help keep patients safe during pain management.
New 2019 standards for nursing homes
The Joint Commission, an accredited body for hospitals and facilities, recently released revisions to its pain management standards for nursing homes. As a former hospital administrator, I can tell you that hospital and facility leaders take note when The Joint Commission issues new requirements, because it puts their accreditation on the line.
In my experience, nursing homes have a higher risk for pain management problems than hospitals. This is largely because nursing homes aren’t required to have a physician on duty or on site 24/7. In some nursing homes that I’ve investigated, a doctor is only on site a few times a week. I’m optimistic that the new Joint Commission standards will help raise the bar in nursing home pain management.
One standard requires a physician medical director to participate in developing and communicating policies, procedures, and guidelines for opioid medications. These include pain assessment, pain management, and monitoring prescribing practices. One of the rationales behind this new standard is that patients in nursing homes frequently take multiple medications, which puts them at risk for drug-drug interactions.
The new standards also require nursing homes to have a leader or leadership team in place to manage opioid painkiller orders, administration, and monitoring on a daily basis.
A new Joint Commission standard requires skilled nursing facilities to offer nonpharmacologic (non-drug) pain management therapies.
Under the new standards, nursing homes are required to provide education and training to staff members and independent licensed providers (physicians, physician’s assistants, and nurse practitioners). This training will include the multiple modalities of pain treatment, early identification and prevention of adverse medication effects, and management of patients with complex needs and medication regimens.
The new standards require nursing home doctors and staff to have access to the Prescription Drug Monitoring Program databases to prevent opioid misuse and diversion.
For patients that require a pain management plan, the new standards require nursing homes to consider the different requirements of patients with acute pain versus chronic pain. Assessment and reassessment are necessary to monitor patient progress in meeting defined pain goals.
Finally, the new Joint Commission standards mandate that nursing facilities have a system to monitor and track the use of opioid pain medications. The rationale for this is clear—opioids are dangerous drugs that remain one of the top preventable causes of injuries in nursing homes.
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Robert Painter is a medical malpractice attorney at Painter Law Firm PLLC, in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits against hospitals, physicians, surgeons, anesthesiologists, and other healthcare providers. A member of the board of directors of the Houston Bar Association, he was honored, in 2018, by H Texas as one of Houston’s top lawyers. Also, in 2018, the Better Business Bureau recognized Painter Law Firm PLLC with its Award of Distinction.