Failure to Document and Timely Administer PRN Pain Medication
Penalty
Summary
Facility staff failed to document the administration of as needed (PRN) pain medication for a resident diagnosed with a displaced closed fracture of the left tibia. The resident and their spouse reported regular occurrences of right leg pain and delays in staff response to call bells, resulting in prolonged periods of unmanaged pain. Despite communication with nursing staff and some improvements, delays in response and medication delivery persisted, particularly during evening shifts. The resident's spouse specifically noted having to return to the facility due to the resident's distress over untimely pain and bedtime medication administration. A review of the resident's care plan and medication administration record (MAR) revealed an order for pain assessment and PRN Tylenol, but no documentation that the medication was administered during the evening shifts on two specific dates. The assigned LPN did not sign off on the MAR for these administrations, even though both the resident and spouse stated the medication was eventually received 30 to 60 minutes after being requested. The deficiency was confirmed through interviews, record reviews, and examination of staffing assignments, with the lack of documentation and delayed response being evident.