Failure to Provide Timely and Documented Pain Management After Surgery
Penalty
Summary
A deficiency occurred when staff failed to provide and document timely and appropriate pain management for a resident admitted after knee replacement surgery. The resident, who had a history of osteoarthritis, fibromyalgia, neuropathy, and recent joint replacement, was at risk for acute pain and had physician orders for both non-pharmacological and pharmacological pain interventions, including acetaminophen, hydromorphone, and tramadol. Despite these orders, there was no documentation that pain medication was administered to address the resident's pain during the initial period after admission, even though pain assessments indicated moderate pain levels. Multiple staff interviews revealed delays in obtaining and administering prescribed pain medications, particularly narcotics, due to issues with receiving signed physician orders and pharmacy delivery schedules. Staff reported that medications, especially controlled substances, were not always available upon admission, and there were delays in entering orders into the electronic medical record system. The resident expressed pain and frustration about not receiving pain medication, and staff acknowledged the expectation that pain medications should be available and administered in a timely manner, especially for post-surgical residents. Documentation in the medical record showed repeated moderate pain scores and limited participation in therapy and activities due to pain. There was also a lack of timely notification to the physician when the resident's pain increased. The facility's policies required prompt assessment and management of pain, but these were not consistently followed, resulting in the resident experiencing unaddressed pain and delays in receiving appropriate pain relief.