Failure to Provide Timely Pain Management
Penalty
Summary
A resident with a history of B-cell lymphoma and left hip pain was admitted to the facility and reported severe pain, rating it as 8-9 out of 10 upon admission. Despite having physician orders for Norco and Tylenol to be administered as needed for pain, the resident did not receive any pain medication from the facility from the time of admission in the evening until the following morning. The resident stated that he was unable to sleep due to pain and resorted to taking his own supply of Norco during the night to manage his discomfort. Documentation in the medical record, including the Medication Administration Record and progress notes, confirmed that no pain medication was administered by facility staff during this period, despite high pain scores being recorded. Facility staff, including the Assistant Director of Nursing, acknowledged that the resident's pain should have been managed better and that medications were available for emergency use. The facility's pain management policy required pain assessments at least every shift and appropriate interventions to be implemented. However, the resident's pain was not addressed in a timely manner, resulting in unmanaged pain overnight and the resident self-administering medication brought from home.