Failure to Provide Timely and Effective Pain Management
Penalty
Summary
A resident identified as being at risk for pain was not provided with effective and timely pain management. The resident had a physician's order for Tramadol-Acetaminophen to be administered every 8 hours as needed for moderate pain, and the care plan included interventions to administer pain medications and evaluate their effectiveness. However, the facility failed to ensure the medication was available, resulting in the resident running out of the prescribed pain medication. Documentation showed the last dose was given on 4/15/25 at 7:00 AM, and no further doses were available after that time. As a result of the medication not being refilled in a timely manner, the resident experienced significant pain, reporting pain levels as high as 8 out of 8 and was observed grimacing and unable to move comfortably. The resident canceled a doctor's appointment due to pain and had to rely on non-prescribed interventions such as positioning for comfort. Staff interviews confirmed that the medication had run out and that agency nurses did not request a refill or new orders. The DON acknowledged that the prescription should have been refilled when four doses remained, but the facility did not attempt to refill it until after the medication was depleted.