Failure to Provide and Communicate Ordered Pain Management
Penalty
Summary
A resident with a history of hypertension, type 2 diabetes, arthritis, and an above-the-knee amputation was admitted to the facility and was cognitively intact, with a language preference other than English. The resident was prescribed ibuprofen for mild pain and Percocet for moderate to severe pain, as needed. However, the resident reported not receiving the previously ordered pain medications and was only receiving Tylenol for pain. The resident expressed confusion about which pain medications were currently ordered and stated that information about pain medications was not communicated in a language he could understand. Record review showed that the resident had not received Percocet after a certain date, despite the orders still being active and available for administration if pain was present. The Medication Administration Record confirmed that only ibuprofen had been administered in recent days. The Director of Nursing verified that the Percocet orders were still active and could have been given. The facility's policy required prompt response to reports of pain and effective communication, but these were not followed, resulting in the resident not receiving appropriate pain management or education about his medications.