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F0600
D

Neglect Due to Withholding of Pain Medication Following Resident Behavioral Symptoms

Wilmington, North Carolina Survey Completed on 12-03-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a nurse failed to protect a resident's right to be free from neglect by withholding prescribed as-needed pain medication. The resident, who had severe vascular dementia with psychotic disturbance, cognitive communication deficit, anxiety, delusional disorder, depression, and chronic pain due to peripheral neuropathy, requested pain medication. The nurse documented that the resident exhibited behaviors such as scratching, biting, and spitting when she entered the room. In response, the nurse left the room without attempting to calm the resident or reapproach, and did not administer the ordered pain medication. The nurse subsequently wasted the medication and did not attempt to administer it later in the shift, nor did she reassess the resident's pain. The nurse acknowledged being aware of the resident's combative and agitated behaviors but chose not to tolerate them, resulting in the resident not receiving pain relief as ordered. Documentation showed the resident had reported a pain level of 6 out of 10, but there was no record of the pain medication being given during the relevant shift. Interviews with facility leadership confirmed that the nurse's actions were inappropriate and constituted neglect. The Director of Nursing and the Nurse Practitioner both stated that pain should have been addressed and the medication administered as ordered, regardless of the resident's behavioral symptoms. The failure to provide pain relief as requested and ordered, and the lack of further assessment or intervention, led to the finding of neglect for this resident.

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