Failure to Provide Timely Pain Management and Reassessment
Penalty
Summary
The facility failed to provide timely and appropriate pain management for two residents with significant medical needs. In the first instance, a resident with an open wound and acute osteomyelitis of the right foot requested pain medication for the first time since admission. After the resident pressed the call light and informed a CNA of the pain, the CNA promptly notified an LVN. However, the LVN did not administer the prescribed acetaminophen until one hour and seven minutes after the request, despite acknowledging that pain should be addressed within 15-20 minutes. Furthermore, the LVN did not reassess the resident's pain level until two hours and thirty-five minutes after medication administration, contrary to professional standards and facility expectations. In the second case, a resident admitted with a femur fracture received PRN oxycodone for severe pain on two occasions. On both occasions, the pain reassessment was conducted more than three hours after medication administration, significantly exceeding the expected timeframe of 30 minutes to one hour. Interviews with facility leadership confirmed that there was no policy specifying the required timeframe for pain reassessment after PRN oral pain medication, and that timely response and reassessment are necessary to ensure effective pain management. These lapses were documented through record reviews, staff interviews, and direct observation.