F0684

G

Failure to Complete Admission Process, Manage Pain, and Act on Chest X‑Ray Results

Clinton, Illinois Survey Completed on 01-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to complete a thorough admission process and to provide timely pain management for a newly admitted post‑surgical resident, as well as a separate failure to act promptly on chest X‑ray results for another resident. One resident was admitted after a left total knee arthroplasty with chronic pain, morbid obesity, and a history of motor vehicle injury, and arrived with orders for multiple pain medications including Hydrocodone, Hydromorphone (Dilaudid), Morphine, and Tizanidine. Hospital documentation indicated she required a gait belt and one‑person assist with a walker for transfers, was cognitively intact, and was being admitted for post‑surgical pain control, with controlled substance prescriptions sent in the discharge packet and Morphine next due at 9:00 p.m. Upon arrival at the facility in the early evening, the resident reported not being greeted or seen by staff for approximately two hours, not having access to a call light, and being placed in a room with a broken bed remote.

When a CNA eventually responded to a call light activated by the roommate, the resident requested assistance to the bathroom. The CNA instructed her to ambulate independently with a walker, despite the resident’s report that she had not walked independently since surgery and was supposed to have staff walking beside her with a gait belt. The CNA watched her ambulate but did not assist with transfers or help her get her legs back into bed. The resident reported being in significant pain, having last received pain medication prior to leaving the hospital, and feeling unsteady and scared of falling. Later, an LPN entered the room, acknowledged knowing the resident was there but did not perform an assessment or evaluate the surgical knee. When the resident requested pain medication and repeatedly reported severe pain and that something did not feel right, the LPN stated she was unsure if any pain medication was available and left without returning with medication. The resident continued to lack ready access to a call light until she later found it on the floor and used it around midnight to again request help for uncontrolled pain.

Around midnight, another LPN assessed the resident, who was in extreme pain, visibly upset, and shaking. This nurse discovered that the controlled substance prescriptions had not been faxed to the pharmacy upon admission and that the admission process, including a full admission assessment and required admission tasks, had not been completed. The prescriptions were not faxed until approximately 1:00 a.m., and the resident had not received any of her ordered pain medications since arrival. A nursing progress note documented that the prescribed pain medications were not delivered by the pharmacy, were not available through the emergency medication supply, and that the prescriptions required refaxing and a new access code. By 1:00 a.m., the resident was tearful, shaking, and stated she could not wait any longer for pain medication, requesting transfer to the emergency room, where she was treated for uncontrolled pain. The regional nurse later confirmed that staff should have greeted the resident upon arrival, ensured access to a call light, notified the pharmacy, faxed prescriptions within two hours, and completed admission assessments including pain, fall risk, transfer status, and care plan focus, and acknowledged that failure to address the resident’s pain caused undue stress and pain.

In a separate incident, another resident with diagnoses including COPD with acute exacerbation and pneumonia underwent a chest X‑ray performed by a private company. The X‑ray report, received by the facility, documented opacities in the right lung base that could represent atelectasis or pneumonia. The facility’s infection control log later showed that this resident was diagnosed with pneumonia of an unknown organism and started on antibiotic therapy several days after the X‑ray. Nursing progress notes documented that nursing staff called the physician regarding the chest X‑ray results and the resident’s condition, describing the resident as extremely congested and coughing, and that the physician’s office returned the call with a new diagnosis of pneumonia and orders for a 10‑day course of antibiotics and DuoNeb treatments as needed.

Despite the new orders, the medication administration record showed that the ordered antibiotic, Amoxicillin, was not actually administered until the evening of the same day the physician’s office returned the call, which was four days after the chest X‑ray results had been reported to the facility. The MAR also reflected the start of Ipratropium‑Albuterol nebulizer treatments as needed for cough, congestion, and shortness of breath beginning on the date the pneumonia diagnosis and orders were received. The DON/Infection Preventionist acknowledged that the delay in initiating antibiotic and respiratory treatment for the resident’s confirmed pneumonia resulted in prolonged infection and symptoms.