Failure to Provide Timely Pain Management as Ordered
Penalty
Summary
A deficiency occurred when a resident with a history of aphasia, cerebral infarction, hemiplegia, and recent right total knee arthroplasty revision did not receive pain management as ordered. The resident had a physician's order for Oxycodone HCL 5 mg orally every 6 hours as needed for pain. On the evening in question, the resident requested pain medication from an LPN at approximately 11:54 PM due to significant knee pain. The LPN did not administer the medication, and the resident did not receive the next dose until 1:28 AM, resulting in an interval of approximately eight hours and thirty-four minutes between doses. The facility's policy required consistent pain assessment and timely administration of pain medication, which was not followed in this instance. Interviews revealed that the LPN was behind on medication administration and told the resident that the night nurse would provide the pain medication, as the LPN needed to finish their shift. The resident, their family member, and a CNA all reported that the resident's request for pain medication was refused or delayed, and the LPN did not assess the resident for pain at the time of the request. The DON confirmed that the LPN failed to follow the physician's order and facility policy by not assessing and administering the pain medication as needed.