Failure to Administer Pain Medication as Ordered and Timely Assess Pain
Penalty
Summary
The facility failed to ensure safe and appropriate pain management for two residents by not administering pain medication as ordered and not performing timely pain assessments. For one resident with a history of lumbar fracture, long-term opiate use, and complex regional pain syndrome, the physician increased the Hydromorphone dosage from 4 mg to 6 mg every 4 hours due to ongoing pain that interfered with therapy and sleep. Despite the new order, the resident continued to receive the lower 4 mg dose until discharge, and there was no documentation that the increased dose was ever administered. Nursing staff did not discontinue the previous order or clarify the duplicate orders, and a pain assessment following the dosage increase was not completed as required by facility policy. Therapy staff documented that the resident experienced severe pain during therapy sessions and sometimes declined therapy due to ineffective pain management. Both the occupational and physical therapists confirmed that pain was a persistent issue and that the resident's participation in therapy was negatively affected by inadequate pain control. The Director of Nursing acknowledged that the physician's new order should have replaced the previous one and that staff should have followed the prescribed orders to manage the resident's pain effectively. For another resident admitted with a right femur fracture and multiple surgical incisions, the facility failed to perform a pain assessment upon admission as required by policy. The first documented pain assessment was not completed until the following morning, several hours after admission. The Director of Nursing and a registered nurse confirmed that the pain assessment was missing from the initial evaluation, which could have delayed identification and management of the resident's pain.