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F0697
D

Failure to Administer Scheduled Pain Medication as Ordered

Gainesville, Florida Survey Completed on 08-29-2025

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 adequate pain management for two residents who were prescribed opioid pain medications. One resident, admitted with multiple diagnoses including bilateral above-knee amputations, Parkinson's disease, and diabetic polyneuropathy, reported not receiving scheduled oxycodone doses every four hours as ordered by the physician. Medication administration records confirmed missed doses on several dates, and the resident stated that staff did not wake him to administer the medication. The resident's care plan specifically included administering analgesia as per orders. Another resident, with diagnoses including paraplegia, chronic pain, and major depressive disorder, also did not receive scheduled oxycodone-acetaminophen doses as ordered for pain rated 7-10. Medication records showed missed doses, and the resident reported not receiving the medication and that staff did not address his concerns. Interviews with the Assistant Director of Nursing and the LPN involved revealed that the LPN did not administer the medications because the residents were asleep, and this action was not in accordance with physician orders.

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