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F0697
D

Failure to Administer Pain Medication According to Physician Orders

Bakersfield, California Survey Completed on 06-12-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to follow the physician's orders for pain management for one resident. Specifically, the resident had physician orders for Tramadol to be administered for moderate pain (pain rating 4-6) and Acetaminophen for mild pain (pain rating 1-3). However, documentation showed that Tramadol was administered when the resident reported severe pain (pain ratings of 7 and 8), and Acetaminophen was given when the resident reported moderate pain (pain rating of 4). During observation, the resident was noted to be moaning and reported a pain level of over 10, while the nurse prepared to administer Tramadol, which was not in accordance with the prescribed pain scale parameters. The resident, who was cognitively intact according to the MDS assessment, reported that Tramadol provided only partial relief and that her pain would return. The facility's policy required licensed nurses to administer pain medication as ordered, but the records and interviews indicated that pain medications were not consistently given according to the specified pain rating parameters. This resulted in the resident experiencing unrelieved pain and pain management that did not align with the physician's orders.

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