Sunny Acres Resident Left in “Excruciating Pain” for Over a Week When Pain Medication Not Refilled

The Illinois Department of Health has cited and fined Sunny Acres Nursing Home when they failed to refill a resident’s critical pain medication patch for over a week despite her repeated requests for help. The cognitively intact 71-year-old resident, who suffered from arthritis and neuropathy, was left in “excruciating pain” for eight days without her prescribed Fentanyl patch, rating her pain as high as a seven out of ten (described as “as bad as it could be”).

The resident was a woman with multiple chronic pain conditions, including primary generalized osteoarthritis and neuropathy. According to her care plan, she was “at risk for pain related to arthritis, neuropathy, GERD.” Her treatment plan included a Fentanyl transdermal patch, a powerful opioid pain medication delivered through the skin, prescribed at 100 micrograms per hour to be changed every three days.

The facility’s Management of Pain Policy states that their mission is to “facilitate resident independence, promote resident comfort and preserve resident dignity” through “an effective pain management program.” The policy emphasizes “promptly and accurately assessing and diagnosing pain” and “monitoring treatment efficacy and side effects.” It specifically notes that pain should be considered the “fifth vital sign” along with temperature, pulse, respiration, and blood pressure. The policy defines pain as “whatever the experiencing person says it is, existing whenever the experiencing person says it does,” acknowledging the subjective nature of pain and the importance of taking residents’ reports of pain seriously.

Despite this policy, the facility failed to provide the resident with her prescribed Fentanyl patch for more than a week. During this period, the resident rated her pain at a level “five” or above eight different times, with at least one rating of seven out of ten, which the facility administrator later acknowledged “indicates pain that is as bad as it can be.”

The resident described her experience: “I wear a pain patch and I did not get my new patch. I kept asking the staff and nothing was done about it. I was told at one point that they needed to get a physician’s order. I don’t know if it was not followed up on or what happened.” She continued, “I was so upset because it had been well over a week that I had waited for the pain patch to be replaced. I was having stabbing pain in my neck and jaw I think from the stress from the amount of pain I was under. I thought I was having a heart attack. I was hurting and frustrated that no one would help me get my medication. I was in excruciating pain for over a week.”

A Certified Nursing Assistant confirmed the resident’s repeated pleas for help, stating, “Every time I would take her meal tray into her [during this period], she would complain of pain and say to me, ‘I just do not understand why they [the staff] are not getting me my pain patch and I have to go this long in pain.'”

Despite the facility’s policy requiring a comprehensive pain assessment when a resident scores five or above on the pain questionnaire, records showed only one comprehensive pain evaluation was completed during the eight-day period when the resident was without her pain medication. This evaluation documented her pain at level seven but noted “no new care plan interventions or clinical suggestions were made to address the resident’s pain.”

When interviewed, the facility’s pharmacist stated they “did not get a request to refill the resident’s Fentanyl” until more than a week after she ran out. The resident’s physician’s nurse confirmed that “our office should have been notified of the need for the Fentanyl Patch refill before the resident ran out.”

The facility Administrator acknowledged multiple failures in care, stating, “When the resident was out of her Fentanyl Patch somebody should have reached out to the physician to get the refill order or to see if the patch could have been pulled from back-up. The staff should have let the physician know that the resident was in pain and see if there was something else we could do to control the resident’s pain. The resident should not have had to go without her Fentanyl Patch.”

The Administrator further explained, “The staff should have contacted me or the Director of Nursing when the Fentanyl Patch was not available so one of us could have followed up on it. There is no documentation that the physician, me, or the Director of Nursing were notified of the resident going without her scheduled Fentanyl Patch or the resident’s complaints of pain.” The Administrator suggested that staffing issues may have contributed to the failure: “During this timeframe we had agency staff taking care of the resident who were not familiar with her. I think that is why there was no follow-up.”

This incident represents a serious failure to follow the facility’s own pain management policies and to provide appropriate care for a resident with chronic pain. The United States Food and Drug Administration Safety Communication specifically warns that “rapid discontinuation [of opioids] can result in uncontrolled pain,” yet the facility allowed this resident to experience an abrupt discontinuation of her pain medication for over a week without appropriate intervention.

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