F0697

D

Failure to Provide Ordered and Appropriate Pain Management for a Resident With Severe Chronic Pain

Stockton, California Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The facility failed to provide pain management consistent with professional standards of practice for a resident with extensive medical conditions and chronic pain. The resident was admitted with chronic pain syndrome, acquired absence of limb, peripheral vascular disease, pressure ulcers, chronic cholecystitis, and end stage renal disease, and had multiple open sores, gangrene, and bilateral lower extremity amputations. Physician orders included acetaminophen 325 mg, two tablets every six hours as needed for mild pain, and oxycodone-acetaminophen 10-325 mg, one tablet twice daily for severe pain. The resident’s care plan indicated the resident was on pain medication therapy related to ESRD, PVD, and multiple wounds, with a goal that the resident would be free of discomfort, and interventions directing staff to administer analgesics as ordered, assess pain intensity, and request changes in the regimen if pain control was not adequate.

From admission and during subsequent stays, the resident repeatedly reported severe pain that was not managed according to the physician’s orders or the resident’s reported pain levels. Nursing progress notes documented that on admission the resident expressed 10/10 pain, refused PRN acetaminophen stating it would not help, and was informed that oxycodone would arrive with the pharmacy delivery, but the ordered oxycodone was not available. On another date, the resident again expressed 10/10 pain, and the charge nurse administered PRN Tylenol despite the order specifying it for mild pain only. Later that same day, the resident was observed yelling and screaming in extreme pain rated 10/10; PRN Tylenol was given at 2100 with no relief, and the scheduled oxycodone dose due at that time was not available because the pharmacy had not delivered it. The on-call pharmacy contact declined to authorize use of the narcotic emergency kit, and the resident continued to report severe pain.

Further documentation and interviews showed that the resident’s severe and moderate pain continued to be treated with a medication ordered only for mild pain, without appropriate physician notification or adjustment of orders. A nursing note indicated the pharmacy had mistakenly faxed the required C-II prescription form to the wrong physician, delaying oxycodone dispensing, and that the resident had been screaming in pain since admission. The pharmacist stated she could have authorized emergency kit use if a physician verbal order had been obtained. Review of the MAR with LN 3 showed that acetaminophen for mild pain was administered on multiple dates when the resident reported severe pain scores of 8–10, and LN 3 acknowledged this did not match the physician’s order and that the physician should have been contacted. Review with LN 2 showed acetaminophen for mild pain was given when the resident reported moderate pain scores of 5–6, and LN 2 acknowledged she should have reviewed the orders, reassessed pain, and contacted the physician for clear PRN orders for mild, moderate, and severe pain. The DON confirmed that there was no order for moderate pain medication, that nurses were expected to contact the physician when pain was not adequately controlled, and stated that pain management for this resident was a concern. Pharmacist interviews confirmed that a delay in receiving the completed C-II prescription and lack of communication from the facility contributed to the unavailability of the ordered narcotic, leaving the resident’s severe pain untreated. Facility policies required assessment for pain, review of physician orders, calling the physician if there was no pain medication order or if medication was ineffective, and monitoring and documenting effectiveness, which were not consistently followed in this case.