Failure to Provide Timely PRN Pain Medication Following Resident Request
Penalty
Summary
The deficiency involves the facility’s failure to provide timely administration of PRN pain medication to a cognitively intact female resident admitted after joint replacement surgery with a left artificial hip joint. Upon admission, the resident had an order for Oxycodone-Acetaminophen 10-325 mg to be given every 4 hours as needed for pain, and her initial care plan directed staff to respond immediately to any complaint of pain. On the evening in question, the resident reported that around 7:00 PM she told a CNA she needed pain medication and was informed it was shift change and it might be a little while before the nurse came. The resident stated that she did not see anyone until approximately 8:30 PM, at which time she reported her pain as 7/10 and appeared grimacing and agitated. The resident’s family member, who was on the phone with the resident at about 8:30 PM, corroborated that the resident said she had requested pain medication at 7:00 PM and had not seen anyone since. The LPN who entered the room around 8:30 PM stated they were not informed in report or by a CNA that the resident had requested pain medication earlier and indicated they would have administered it sooner if they had known. Documentation showed the resident received Oxycodone just before 2:00 PM and then not again until 8:30 PM, a 6.5-hour interval, despite the order allowing dosing every 4 hours as needed. The DON stated that a resident’s pain level is what they say it is and that CNAs are expected to notify the nurse when a resident requests pain medication so the nurse can act, underscoring that this communication did not occur as required by the resident’s care plan and the facility’s pain management policy.
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