Failure to Follow PRN Pain Medication Parameters After Resident Fall
Penalty
Summary
The facility failed to administer pain medication in accordance with a physician’s order based on a documented pain scale for one resident. The resident was admitted with diagnoses including atrial fibrillation, muscle weakness, and a non-displaced fracture of the right medial malleolus. An MDS assessment indicated the resident had severely impaired cognition and required staff assistance with oral, toileting, and personal hygiene. The physician’s order, dated 6/29/2025, specified acetaminophen 325 mg, two tablets by mouth every four hours as needed for mild pain rated 1–4 on a 0–10 pain scale. The resident’s care plan for chronic pain/discomfort included an intervention to provide consistent and sufficient pain medication tailored to the individual. On a date in December, the resident experienced an unwitnessed fall resulting in a bump to the right forehead and severe forehead pain rated 8/10 on a pain scale. An SBAR form documented the fall, the severe forehead pain, and that an ice pack and Tylenol were provided, without specifying the dose. The MAR for that month showed that acetaminophen was administered at 8:45 p.m. for forehead pain with a documented pain level of 7/10. The LVN later stated the resident had reported pain at 8/10, that acetaminophen was given for this level of pain, and that the MAR entry of 7/10 was incorrect. During interview and record review, the ADON confirmed that acetaminophen 325 mg, two tablets, was administered for a reported pain level of 7/10, acknowledged that the order limited use to pain levels 1–4/10, and stated the physician should have been contacted for a stronger pain medication appropriate to the higher pain level. Facility policies on pain management and medication administration required pain assessment with documented ratings and administration of medications as prescribed by the physician.
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