Citation Number: 030005797
Citation Date: 1/16/2009
Violation Date: 8/21/2008
Class: AA
Penalty: $ 100000

On 8/20/07, an 83 year old resident fell against the footboard of his bed, hitting his chest and fracturing multiple ribs. Despite severe pain, the resident was not transferred to the hospital, but was instead kept in the facility and given several increasingly large and frequent doses of the pain medication, Roxanol. By the following morning, the resident's oxygen saturation dropped to a life threatening level, but the facility did not administer oxygen per its policy or consult with his doctor for oxygen therapy. After suffering excruciating, unrelieved pain for about 21 hours, the resident died about 50 minutes after being given an excessive dose of the narcotic pain medication (40 mg of Roxanol within a one-hour period). The facility did not attempt to obtain other treatment options or a higher level of care even though the resident sustained an acute injury and the facility's care was inadequate to relieve the severe pain that he suffered.