F0656

D

Failure to Implement Pain Management Orders and Omit Fluid Restriction from Care Plan

Norfolk, Virginia Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

Facility staff failed to implement a comprehensive care plan for pain management for one resident following admission from the emergency room. The resident had a surgical wound related to a laminectomy and was assessed on the admission MDS as having a surgical wound, receiving scheduled pain medication, and experiencing occasional pain. The care plan identified actual impaired skin to the lower back related to laminectomy and pain related to the surgical wound, with an intervention to treat pain per orders prior to treatment or turning. The ER discharge summary and physician orders specified Hydrocodone-Acetaminophen 5-325 mg by mouth every 4 hours for 5 days, with the facility order entered on 3/29/2024. However, the eMAR showed that multiple scheduled doses from the evening of 3/29/2024 through the afternoon of 3/30/2024 were not administered.

Progress notes documented that pharmacy reported not receiving the faxed or e-scribed prescription, and nursing staff made repeated calls to the pharmacy and on-call provider, with instructions at one point to hold the medication until the provider could send a prescription. Later documentation indicated the facility was still waiting for pharmacy delivery while the physician was aware. Despite this, the DON confirmed that the facility maintained an in-house stock of Hydrocodone-Acetaminophen 5-325 mg tablets and that all nurses had access to this stock via a code from the pharmacy, with a witness required for narcotics. Multiple nurses, including an RN, a unit manager LPN, and another LPN, stated that urgent medications could be pulled from in-house stock or obtained stat from the pharmacy, and that this in-house system had been in place for several years. The facility’s own comprehensive care plan policy required implementation of all services identified in the assessment to meet residents’ needs and professional standards of quality.

Facility staff also failed to develop a comprehensive care plan addressing fluid restriction monitoring for another resident. This resident was admitted with diagnoses including intracranial hemorrhage, diabetes mellitus, and transient ischemic attack, and was cognitively intact per a BIMS score of 13. The resident required maximal assistance for bed mobility, transfers, and hygiene, and had a physician’s order for a fluid restriction of 1420 cc per day. The comprehensive care plan in place focused on ADL self-care performance deficits related to impaired mobility and included an intervention to praise all efforts at self-care, but did not address the ordered fluid restriction. Review of the MAR/TAR for January and February and the resident’s meal slips showed no evidence of fluid restriction monitoring, and the resident reported not being aware of being on a fluid restriction. An LPN stated that fluid restriction monitoring would involve watching intake and acknowledged that such a restriction should be included on the care plan.