Failure to Obtain and Document Timely Admission Physician Orders and Pain Management
Penalty
Summary
The facility failed to obtain and document timely physician orders for immediate care upon the admission of a resident who had recently undergone major spinal surgery and had complex medical needs, including a surgical site with staples and a Foley catheter. Despite the resident's transfer from the hospital with clear medication orders for pain management and other routine medications, the facility did not enter these orders into their system or administer the medications until the day after admission. There was no evidence that the facility contacted the physician to obtain necessary orders for pain medication, surgical site care, or Foley catheter care at the time of admission. The resident was admitted in the evening, alert and oriented, but dependent for all activities of daily living and with a history of metastatic cancer and recent surgery. Family members reported that the resident experienced significant pain upon admission, and that pain medication was not provided despite their concerns and communication with facility staff. Nursing documentation and interviews confirmed that pain assessments were not completed as required by facility policy, and that no pain reassessment or documentation occurred during the initial shift. The nurse responsible for the admission acknowledged forgetting to contact the physician for orders and failing to reassess or document the resident's pain. Further review of the medical record showed that none of the resident's routine or as-needed medications, including those for pain, were administered until the following day. The facility's own policies required pain observation and documentation at admission and when pain status changed, but these steps were not followed. Interviews with staff and the DON confirmed that the expected process was not carried out, resulting in a lack of timely physician orders and medication administration for the resident's immediate care needs.