F0697

D

Failure to Provide Ordered Oral Pain Medication and Adequate Pain Assessment

Glendale, California Survey Completed on 01-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide ordered pain management for a resident with a toothache and facial swelling. The resident was admitted with encephalopathy, epilepsy, and hypertension, was bedbound with decreased tone and no movement on the right side, and had severely impaired cognitive skills per the MDS. The MDS also showed the resident required substantial assistance with ADLs and that the staff assessment for pain was left blank, with no pain management regimen documented and the resident denying pain at that time. The care plan, revised in November, identified dental health problems related to poor oral hygiene and missing teeth, with interventions to monitor, document, and report signs and symptoms of oral or dental pain.

On 12/27/2025, a change of condition evaluation documented mild swelling of the lymph nodes and left cheek, and a pain level of 5/10 in the upper left jaw. A physician order dated 12/27/2025 directed that the resident receive Orajel 2X Toothache & Gum Mouth/Throat Gel 20-0.26%, one application by mouth every six hours as needed for toothache for seven days. There was also an existing PRN order for acetaminophen 325 mg, two tablets by mouth every four hours as needed for moderate pain (pain scale 4–7), and an order to monitor the resident’s pain level every shift using a pain scale. However, review of the December MAR showed no documented evidence that the resident received either acetaminophen or Orajel from 12/27/2025 to 12/29/2025, and the MAR entries for those dates indicated the resident denied pain.

Family members reported that during the three days after the Orajel was ordered, they frequently informed nursing staff that the resident was having mouth pain and discomfort, and were repeatedly told the medication had not yet arrived from the pharmacy. One family member stated the Orajel was not delivered until 12/30/2025 and that nothing was done until that day, despite offering to pick up the medication. The resident later reported experiencing frequent pain at 8/10 severity in the upper left jaw during that period and difficulty eating, having to chew on the right side and eat slowly. The Director of Staff Development confirmed that the Orajel was ordered on 12/27/2025 but first administered on 12/30/2025, and that there was no documented evidence of Orajel or Tylenol administration or of a thorough pain assessment, including pain level, location, frequency, and description, from 12/27/2025 to 12/29/2025. The facility’s pain protocol required assessment at onset of new pain or worsening pain, identification of pain characteristics, and regular reassessment, which were not documented as having been carried out during this time.

The deficiency is that the facility failed to provide the ordered Orajel for three days after the physician’s order for toothache pain and failed to document and perform thorough pain assessments despite reports of pain and an existing pain monitoring order. As a result, the resident reported consistent pain at 8/10 and difficulty eating during that period, which the report states could lead to weight loss and/or prevent participation in ADLs, affecting quality of life.