Failure to Appropriately Assess and Manage Pain After Readmission
Penalty
Summary
A resident with a history of traumatic subdural hemorrhage, cerebral infarction, heart failure, and spinal stenosis was readmitted to the facility following a hospital stay. Upon readmission, the resident reported pain and rated it as a three out of ten. The resident received a dose of oxycodone 5 mg on the evening of readmission, based on a previous order that was no longer valid, as the hospital discharge orders did not include oxycodone. Subsequent to this dose, the resident continued to report pain but did not receive further pain medication because there was no current physician order for it on file. Staff interviews confirmed that the resident repeatedly voiced complaints of pain, but no additional pain medication was administered after the initial dose due to the lack of a valid order. The facility's pain management policy required assessment and management of pain consistent with professional standards and the resident's care plan, including upon admission and significant changes in condition. The failure to obtain a new order and provide appropriate pain management resulted in the resident experiencing untreated pain following readmission.