Failure to Provide Timely and Appropriate Pain Management
Penalty
Summary
A deficiency was identified when a resident with a fractured right tibia and multiple surgical staples reported ongoing moderate to severe pain that was not effectively managed according to professional standards. Upon admission, the resident was alert, oriented, and able to communicate needs, but was only provided acetaminophen for pain, which was ordered for mild pain. Despite the resident reporting pain levels of 7/10 and 8/10, which indicate moderate to severe pain, acetaminophen continued to be administered, and there was no evidence of further action to address the resident's discomfort. The resident communicated to staff that the prescribed pain medication was not effective, but it took 13 days from admission before the physician was contacted and an order for Tramadol, appropriate for moderate to severe pain, was obtained. The DON confirmed that the pain management provided was not consistent with the resident's needs and that the physician should have been notified sooner. The facility failed to follow its own pain management policy and did not ensure timely and appropriate pain relief for the resident.