Failure to Provide Timely Pain Management as Ordered
Penalty
Summary
A deficiency occurred when a resident who was frequently in pain and had physician orders for as-needed pain medications did not receive pain management as ordered. During incontinent care, the resident expressed pain, was observed groaning, and reported discomfort to the CNAs. The resident's orders included Tylenol 325 mg two tablets by mouth every six hours as needed and oxycodone HCl 5 mg, with specific dosing based on pain level. The medication administration record showed the last dose of oxycodone was given at 5:06 a.m., and the next dose was not administered until 1:07 p.m., despite the resident expressing pain around noon. Tylenol was not administered during this period. CNA staff reported the resident's pain to the CMA, who stated it was too early to administer additional pain medication and that the resident had already received all available pain relief. However, upon review, the CMA acknowledged a miscalculation and that the resident should have received pain medication when they complained. The DON confirmed that the CMA did not follow the resident's pain management orders. The failure to provide timely pain medication as ordered resulted in the resident experiencing unmanaged pain during the observed period.