Failure to Administer and Document Ordered Post‑Operative Pain Medications
Penalty
Summary
The deficiency involves the facility’s failure to provide safe and appropriate post‑operative pain management for one resident (R3) by not administering ordered pain medications, not monitoring and documenting pain relief, and not implementing care‑planned non‑pharmacological interventions. R3, who had a history including lumbosacral and pelvic fractures with routine healing, motor vehicle accident injury, anemia, and anxiety disorder, reported that his pain was not being controlled and that staff told him there was no oxycodone order despite it being listed on his discharge summary. Physician orders dated 1/27/2026 included oxycodone 10 mg by mouth every 4 hours as needed for pain and acetaminophen 325 mg, three tablets by mouth every 6 hours as needed for pain. On multiple observations, R3 rated his pain as 10/10 and stated that the facility was not getting his pain medication orders straight. During medication pass, an LPN assigned to R3 stated that his pain medication was not scheduled, did not know when he last received pain medication, and reported that there was no oxycodone in the narcotic box at that time. Later, the DON stated that R3 did have an oxycodone order and that the medication was in stock, explaining that the nurse had been unable to find it earlier. On another observation during a dressing change, swelling and tenderness were noted at R3’s right hip surgical site, and he again rated his pain as 10/10. R3 later reported that the facility had run out of pain medication again and that he had not received any pain medication for the past two days. An RN acknowledged that R3 received oxycodone every 4 hours, that the medication had to be reordered and sometimes ran out, and that R3 would not take Tylenol and only wanted oxycodone. Review of the care plan initiated 2/10/2026 documented that R3 was at increased risk for alteration in pain/discomfort, with goals and interventions including administering analgesics as ordered, offering PRN analgesics prior to ADLs/rehab/wound care, observing for effectiveness of pain relief, and notifying the physician for new pain complaints or signs/symptoms of pain. However, review of the MAR for January showed that oxycodone or Tylenol were not signed out as given from admission through the end of the month, despite pharmacy records showing delivery of oxycodone 10 mg tablets on 1/31/2026. The DON could not locate the narcotic receipt and disposition form for January. For February, oxycodone was signed as given only about five times and Tylenol was not signed out at all, even though pharmacy manifests showed additional oxycodone deliveries. The DON stated that R3 was getting oxycodone and that nurses were not signing the MAR, and acknowledged that R3 was supposed to be offered Tylenol and refusals documented. Facility policies required medications to be administered as prescribed, MARs to be signed by the person administering, and PRN medications to be fully documented, as well as guidelines emphasizing effective pain management and recognition that pain is what the resident says it is. These failures contributed to R3 suffering psychological harm and feeling hopeless because no one cared about his pain or healing, with pain rated 10/10.
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