Failure to Notify Physician and Adjust Pain Management for Resident
Penalty
Summary
A deficiency occurred when the facility failed to manage pain effectively for a resident with a recent fall and a fractured left arm, as well as other medical conditions including heart failure and hypertension. The resident was prescribed Oxycodone-Acetaminophen 10-325 mg every six hours for moderate to severe pain. Despite this, the resident repeatedly reported that the pain medication wore off after three to four hours and requested more frequent dosing for better pain relief. Staff interviews confirmed that the resident consistently complained of pain and requested medication before the scheduled time, but the physician was not notified of the ongoing pain or the resident's request for a change in medication timing. The care plan for the resident included monitoring the effectiveness of pain interventions and notifying the physician if pain was not controlled. However, the assigned LVN did not report the resident's continued pain or request for more frequent medication to facility leadership or the physician, despite being instructed to do so by the RN and DON. The facility's pain management policy required documentation of the effectiveness of PRN medications and physician notification if pain was not managed, but these steps were not followed, resulting in the resident remaining uncomfortable and waiting for the next scheduled dose while in pain.