F0697

G

Failure to Administer Ordered Opioid and Assess Pain Resulting in Unrelieved Severe Pain

Peoria Heights, Illinois Survey Completed on 02-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide safe and appropriate pain management for a resident with multiple pain-related diagnoses, including age-related osteoporosis, fibromyalgia, complex regional pain syndrome of the upper limb, a periprosthetic fracture around a prosthetic left knee joint, and an unspecified fracture of the lower end of the left femur. The resident had a physician’s order for Hydrocodone-Acetaminophen 5-325 mg, one tablet every six hours for pain management, and a care plan identifying potential for pain related to recent fracture, recent surgery, and fibromyalgia, with approaches to administer medications as ordered, assess for signs of pain, and notify the physician if pain medications were ineffective. The facility’s own Pain Management and Pain Assessment policies required pain assessments at admission and with condition changes, use of pain assessment tools, documentation of pain assessment and monitoring, and administration of medications as prescribed.

Despite these orders and policies, the resident’s scheduled Hydrocodone-Acetaminophen dose was not administered on one evening, and then all 12 scheduled doses over the following several days were not given. Medication administration records and order administration notes documented that the medication was unavailable in the cart and then listed as “on order,” and a health status note indicated the prescription had been faxed to the physician and a refill was awaited. During this period, there was no documentation of any PRN pain medications being given, no non-pharmacological pain-relieving interventions, and no comprehensive pain assessments, even though the resident was not receiving the prescribed opioid. The electronic medical record lacked evidence of physician notification regarding the missed doses, the unavailability of the medication, or the resident’s ongoing pain during the time the medication was not administered.

Interviews corroborated that the resident experienced severe, unrelieved pain and that staff were aware of her complaints. The resident reported being in severe pain, crying out, unable to move or get comfortable, and being told by staff that there was nothing they could do while her pain medication was out and awaiting a signed prescription. An LPN stated the resident was not receiving her pain medications as she should have and frequently complained of left leg pain, and was not aware of any other pain-relieving interventions during the time the Hydrocodone-Acetaminophen was unavailable. The administrator-in-training acknowledged the resident had filed a grievance about being out of pain medication and being in pain, and stated the facility was waiting for the prescription to be filled and that the resident should not have gone without her pain medication. The facility medical director and nurse practitioner both stated they expected to be notified if there were issues obtaining the resident’s pain medication so that alternative pain relief could be ordered, and the corporate/interim DON verified that all scheduled doses were missed over several days with no PRN pain medications or interventions and no documented physician notification. Other staff, including an occupational therapist and another LPN, confirmed the resident complained of pain frequently, and the MDS coordinator confirmed that no electronic pain assessment had been completed during the resident’s stay, despite policy requirements.