Failure to Provide Timely Pain Management for Resident with Chronic Pain
Penalty
Summary
A resident with multiple wounds, cellulitis of the perineum, and a history of pain and chronic pain was admitted to the facility and did not receive ordered pain medication in a timely manner. Upon admission, the resident complained of severe pain, but the admitting LPN did not have pain medication available and failed to follow the facility's process for obtaining pain medications, which included contacting the pharmacy or physician. The LPN also did not assess or document a pain scale score, despite the resident experiencing significant pain during the shift. Documentation in the health status note confirmed the resident was in pain and that no medications were on hand. The facility's medication dispensing system had the ordered pain medication available, but it was not accessed or administered to the resident as required. The DON confirmed that the process for obtaining pain medication was not followed and acknowledged that the resident's pain level was not properly documented. The EMAR showed that the resident did not receive the ordered pain medication on the day of admission, despite an active order for Hydrocodone-Acetaminophen. The resident's representative and staff interviews corroborated that the resident experienced severe pain and did not receive timely pain management during the facility stay.