Failure to Provide Timely and Effective Pain Management
Penalty
Summary
The facility failed to ensure effective pain management for a resident admitted with a left lower leg fracture, chronic pain, and anxiety. Upon admission, the resident had physician orders for Tylenol and oxycodone-acetaminophen as needed for pain. However, due to an issue with obtaining a resident identification number, the pharmacy was unable to fill the oxycodone-acetaminophen prescription, resulting in the resident only receiving Tylenol for pain management. Documentation shows that Tylenol was administered when the resident reported significant pain, but the stronger pain medication was not given until much later, despite the resident experiencing severe pain that was not adequately controlled by Tylenol alone. Interviews with the resident and nursing staff confirmed that the resident experienced severe pain, rating it as high as ten out of ten, and that the Tylenol provided only minimal and short-lived relief. Nursing staff communicated the medication issue to administration and the DON, but delays persisted in providing the prescribed pain medication. Additionally, there was inaccurate documentation of the resident's pain level in the medical record. The facility's pain management policy requires that pain management be consistent with professional standards and resident preferences, which was not met in this instance.