Failure to Administer PRN Pain Medication After Resident Fall
Penalty
Summary
The facility failed to administer pain medication as ordered for a resident who exhibited clear signs and symptoms of pain following a fall. The resident, who had an active order for acetaminophen 325 mg every 4 hours as needed for mild pain, was found sitting on a floor mat in her room, moaning, groaning, unable to lift her right arm, and verbally expressing pain in her right shoulder. Despite these observations and the resident's complaints, there was no documented evidence that the as-needed pain medication was administered prior to her transfer to the hospital for further evaluation. Record review confirmed that the medication order was in place and that the resident's electronic medication administration record (EMAR) did not show administration of the pain medication after the incident. The assistant director of nursing (ADON) verified that the nurse should have provided the ordered pain management when the resident displayed symptoms and verbalized pain. Facility policy on pain assessment and management required implementation of pain management strategies based on the resident's needs, including the use of PRN medications for breakthrough pain, which was not followed in this case.