Failure to Provide Timely Pain Management After Admission
Penalty
Summary
A deficiency occurred when a resident admitted for aftercare following joint replacement surgery did not receive appropriate pain management upon admission. The resident, who was cognitively intact and able to communicate, reported that her last dose of pain medication was administered at the hospital prior to admission, and she did not receive any pain medication from the facility until the following day. Nursing documentation confirmed that the resident complained of pain in her left knee, rated as a level 3, but no pain medication was administered on the day of admission, despite physician orders for both acetaminophen and Roxicodone for varying levels of pain. The Medication Administration Record showed no administration of either acetaminophen or Roxicodone on the day of admission, and the first recorded dose was given the next morning, with no documented monitoring of its effectiveness. The DON confirmed that the ordered controlled pain medication was available in the facility's emergency medication supply but was not administered as required. Facility policies reviewed indicated that pain management should be provided according to professional standards and that nurses should obtain needed medications from emergency supplies if unavailable, but these procedures were not followed in this instance.