Failure to Provide Timely Pain Management for Newly Admitted Resident
Penalty
Summary
A newly admitted resident with a complex medical history, including chronic pain, fibromyalgia, polymyalgia rheumatica, and other conditions, reported severe pain rated at 8 out of 10 upon arrival at the facility. The resident's hospital discharge summary included orders for multiple pain medications, including acetaminophen, cyclobenzaprine, and oxycodone-acetaminophen, all to be administered as needed. Despite these orders and the resident's clear communication of pain to nursing staff, no pain medication was administered on the day of admission or the following day, as documented in the Medication Administration Record (MAR). Multiple staff interviews revealed confusion and lack of preparedness during the admission process. Nurses reported not having access to the resident's pain medications due to delays in processing orders and lack of access to the Emergency Kit (E-Kit). One nurse, new to the facility, stated she could not administer any medications until they appeared in the electronic health record, while another contract nurse did not know the location of the E-Kit and did not seek assistance or notify the physician. The resident was instead provided with non-pharmacological interventions such as an ice pack and a fan, but these did not address her reported pain. The facility's pain management policy required prompt assessment and management of pain, including notifying the primary care provider if pain was indicated and following prescribed orders for pain management. However, the policy was not followed, as the resident's pain was not treated according to physician orders, and there was no documentation of pain medication administration or effective communication among staff to resolve the issue. The Director of Nursing acknowledged that expectations for pain management were not met for this resident on the day of admission.