F0755

D

Failure to Provide Timely Pain Control, Routine Medications, and Accurate MAR Documentation

Olney, Illinois Survey Completed on 01-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide timely routine and emergency medications and to accurately document medication administration for a resident with multiple serious diagnoses, including COPD, Type 2 diabetes, CHF, small cell B lymphoma, and hypertension. The resident was admitted with numerous scheduled medications (Eliquis, Lasix, metoprolol, potassium chloride, magnesium oxide, folic acid, vitamin D3, inhaled/nebulized respiratory medications, and others) and PRN Tylenol for pain. On the evening of admission, the resident’s evening medications were not administered because they were unavailable due to delayed pharmacy delivery, and the MAR documented that no scheduled evening medications were given for that reason. The facility did not utilize the emergency medication kit or request a STAT delivery from the pharmacy, despite the pharmacy’s later statement that most commonly used medications and controlled substances were available in the e-kit and that a STAT delivery could have been guaranteed within four hours if requested.

During repositioning in a recliner around dinner time, two CNAs lifted the resident without a gait belt, and a popping sound was heard from the resident’s left arm, after which the resident complained of pain and stated his arm was broken. Nursing assessment later that evening documented minimal movement below the elbow, inability to move the arm above the elbow without serious pain, and decreased range of motion, and an on‑call physician ordered a portable x‑ray, which showed a pathological transverse fracture of the left humerus. The only pain medication available and ordered that evening was PRN Tylenol, which was administered around 9:29 p.m. and provided some relief, but the family reported the resident was in horrible pain, moaning, and screaming out with repositioning. Staff did not obtain or attempt to obtain narcotic pain medication from the pharmacy or the e-kit that night, despite the on‑call physician later stating he could have provided an order and that an e‑script could have been used to access narcotics from the e‑kit.

The following morning, the resident continued to experience severe pain rated 10/10. The RN on duty administered Tylenol around 6:30 a.m., which was documented as only slightly effective, and contacted the primary care physician, who ordered hydrocodone‑acetaminophen PRN for pain and directed that Eliquis be held pending goals‑of‑care clarification. However, due to the physician not being in his office to e‑script immediately, the facility did not obtain the narcotic from the e‑kit until after 10:20–10:29 a.m., and the resident remained in severe pain until that time. Additionally, the RN documented that several morning medications (Eliquis, magnesium oxide, vitamin D3, folic acid, and Lasix) were charted as given on the electronic MAR but were in fact not administered due to family questions and pharmacy delivery delays; the nurse stated there was no way to uncheck medications once marked as given in the eMAR. The DON and pharmacist confirmed ongoing problems with obtaining narcotics and new‑resident medications from the contracted pharmacy, and the pharmacist confirmed that the facility did not call for e‑kit codes or request STAT delivery for this resident’s medications, despite policy stating that emergency pharmacy service and e‑kit access are available 24/7 and that medications must be administered and documented in accordance with prescriber orders.