Failure to Administer and Document Pain Medication Following Resident Injury
Penalty
Summary
A resident with a history of bilateral osteoarthritis, muscle wasting, and cognitive impairment sustained a fall resulting in a head injury and later discovered femoral neck fracture. Following the fall, the resident exhibited signs of pain, including facial grimacing and withdrawal upon touch, as documented by therapy and nursing staff. Despite a physician's order for acetaminophen as needed for discomfort, the medication was not administered when pain was observed, nor was it documented as given prior to transfer to the emergency department. Nursing staff, including an LPN and the ADON, noted the resident's pain but did not provide pain medication. The ADON reported offering acetaminophen, which the resident refused, but did not document this interaction or make further attempts to administer pain relief, despite the resident's cognitive impairment. Other staff members were unaware of the resident's injury or need for pain management prior to transfer, and the medication administration record did not reflect that acetaminophen was given at the appropriate times. Facility policy required staff to identify and manage pain, reassess regularly, and document all care and changes in the resident's condition. Interviews with staff and review of records confirmed that pain management was not provided or documented as required, and that communication among staff regarding the resident's pain and injury was insufficient. The failure to administer and document pain medication as ordered and indicated by the resident's condition constituted the deficiency.