Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide timely and appropriate pain management for a resident admitted with multiple medical conditions, including spondylolisthesis, lumbar region, and compression fractures. Upon admission, the resident had physician orders for pain assessment every shift and for 10 mg oxycodone to be administered every four hours as needed for pain. However, the resident did not receive a pain assessment or the prescribed pain medication for approximately two and a half days after admission. The medication was not available in the facility until 7:28 P.M. on the third day, and the first dose was administered at 7:44 P.M. the same day. Documentation confirmed that the resident experienced significant pain during this period, with a pain rating of six out of ten, and reported being unable to get out of bed due to pain following surgery and internal stitches. Interviews with facility staff, including the DON and ADON, revealed that the delay in pain management was due to failures in ordering and following up on the resident's pain medication. Staff did not complete the required pain assessments, and there was a lack of communication and accountability regarding the ordering and administration of the prescribed oxycodone. The facility's own pain management policy, which required assessment and collaboration with the physician to manage pain, was not implemented in this case. The resident reported that staff blamed each other for the delay, and the facility's investigation confirmed the medication was not ordered or available as required.