F0684

D

Failure to Provide PRN Pain Medication After Resident’s Return From Hospital

Pine Bluff, Arkansas Survey Completed on 01-22-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide prescribed and requested PRN pain medication to a resident following a return from the hospital. The resident had been admitted with diagnoses including bipolar disorder, current episode manic severe with psychotic features, and had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. The resident’s MDS documented verbal behavioral symptoms directed toward others, dependence for toileting/personal hygiene, a history of multiple falls, and use of high‑risk medications including antianxiety agents, antidepressants, opioids, and anticonvulsants. The care plan, revised in late February, identified a behavior problem of agitation related to communication, including that the resident would throw themself on the floor if verbalized demands were not instantly met, and also identified a risk for pain with an intervention to anticipate the resident’s need for pain relief and respond immediately to any complaint of pain. The eMAR for January showed an active PRN pain medication order to give one tablet orally every four hours as needed for pain, with ongoing pain monitoring orders.

On the night in question, the resident returned from the hospital around 10:30 PM. After being put to bed, the resident requested pain medication for head pain. CNA staff reported informing an LPN that the resident was requesting pain medication. The CNA later stated that around 12:30 AM, the resident continued calling out for help and reporting pain, and the CNA again went to the nurse. The CNA further reported that around 5:00 AM, the resident was still awake and asking for medication for head pain, and the CNA again approached the same LPN, who refused to administer pain medication, stating that another LPN, who was not present in the building, had agreed to pass medications on that hall. The CNA stated that the LPN did not go to the resident’s room at all during the shift and did not provide any pain medication despite multiple requests relayed by the CNA.

Documentation and interviews showed that the LPN on duty had accepted the keys to all medication carts and was the only nurse listed on the staffing log for that night, with no timecard entries indicating that the other LPN was working or present. The LPN’s own witness statement indicated they signed for the resident’s return from the hospital and that a co‑worker handled all medications for the hall where the resident resided, and that they rarely appeared on that hall. However, the daily staffing log and timecard records showed no other LPN assigned or clocked in after an earlier date. The DON and another LPN stated that the nurse who accepts the keys to all medication carts and is the only nurse in the building is responsible for addressing any resident’s request for medication, including pain medication. Review of the MAR during the facility’s investigation confirmed that no pain medication was administered to the resident during the period when the resident repeatedly requested it after returning from the hospital.

Additional interviews supported that the resident was distressed the following morning. Social Services reported finding the resident lying on a mat on the floor the morning after the incident, with the resident voicing being mad, though not specifying the reason. The Administrator stated that there was no written communication from the LPN about what was occurring in the resident’s room and that the LPN did not always communicate back with administration. Facility policies on administering medications required that medications be administered in a safe and timely manner as prescribed, and the Abuse Prevention Program policy required the administration to protect residents from abuse and neglect. The Office of Long‑Term Care Incident and Accident report categorized the event as abuse and neglect, noting that the resident was sent to the hospital after a fall and, upon return, requested pain medication twice with no medication provided, and that the alleged perpetrator was a facility employee.