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F0697
D

Failure to Provide Effective Pain Management for Residents with Severe Pain

Coronado, California Survey Completed on 05-02-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide effective pain management for two residents with significant pain-related diagnoses. One resident with a coccyx pressure injury and paraplegia reported that the pain medication administered by the facility was ineffective. Review of physician orders showed that this resident was prescribed Norco 5-325 mg for moderate pain and Norco 10-325 mg for severe pain. However, when the resident complained of severe pain, only the lower dose of Norco 5-325 mg was given, contrary to the physician's order for severe pain. Another resident with severe discitis and osteoarthritis also experienced issues with pain management. This resident was prescribed Roxicodone 5 mg for moderate pain and Roxicodone 10 mg for severe pain. When the resident reported severe pain, the correct dose of Roxicodone 10 mg was administered, but a reassessment shortly after showed the pain remained severe. The licensed nurse did not notify the physician about the unrelieved severe pain, as required by facility policy. Both incidents were acknowledged by facility clinical leadership as failures to follow physician orders and internal protocols for pain management.

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