Failure to Provide Ordered Pain Management for Resident
Penalty
Summary
A resident with a history of polyneuropathy, repeated falls, and diabetes mellitus was admitted to the facility and had an active order for acetaminophen 1000 mg by mouth every 6 hours as needed for severe pain, specifically for pain rated between 7/10 and 10/10. The resident was assessed as able to express needs and had no impairment in upper or lower extremities. On multiple occasions, the resident reported pain at a level of 7/10, particularly after being struck under the left eye by another resident. Despite the resident's repeated reports of severe pain, documentation on the Medication Administration Record (MAR) showed that no pain medication was administered during four nursing shifts when the resident reported pain at the threshold specified in the physician's order. Both the LVN and the DON confirmed during interviews and record reviews that the pain was documented but not treated according to the standing order. Facility policies and procedures required that medications be administered in accordance with prescriber orders and that staff identify and address residents' pain. However, the staff failed to provide the ordered pain management, resulting in the resident experiencing unrelieved pain that had the potential to interfere with activities of daily living.