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F0697
D

Failure to Provide Timely Pain Medication to Newly Admitted Resident

Springfield, Illinois Survey Completed on 08-01-2025

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

A newly admitted resident with a history of osteoarthritis and recent right hip joint replacement surgery did not receive prescribed pain medications as ordered upon admission. The resident's care plan identified a risk for pain related to osteoarthritis and reverse total hip arthroplasty, with physician orders for Hydrocodone-Acetaminophen and Tramadol to be administered every six hours as needed for pain. However, medication administration records and controlled substance logs show that neither medication was given on the evening of admission, and the first documented administration occurred the following morning. Interviews with facility staff revealed that the pain medications were not available when needed, with an LPN stating that the pharmacy delivery was late and that only certain staff had access to the medication distribution machine. The resident reported experiencing significant pain and poor sleep due to the lack of timely pain management. The Director of Nursing confirmed that newly admitted residents are expected to receive their medications on time and that staff have the ability to access medications from the distribution machine. The facility's pain management program emphasizes effective pain control to promote healing and wellness, but this was not achieved in this instance.

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