F0684

D

Failure to Follow Physician Orders for Pain Management and Staple Removal

Redmond, Washington Survey Completed on 02-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow physician orders for pain management and treatment as outlined in its own policy on medication and treatment orders. For one resident admitted with orthopedic aftercare and left knee osteoarthritis, the hospital After Visit Summary listed acetaminophen 500 mg, two capsules by mouth every eight hours. On admission, the facility’s Licensed Nurse Pain Management Review documented that the resident had endorsed pain or discomfort in the left knee in the past five days and recommended initiating a pain plan of care. The facility’s Order Summary Report showed a physician order for acetaminophen 1000 mg by mouth three times a day for pain starting the day after admission, and the MAR reflected scheduled doses beginning that day at 8:00 a.m., 2:00 p.m., and 8:00 p.m. However, there was no documentation that the resident received any pain medication on the day of admission, despite the availability of OTC medications and the expectation that hospital discharge orders would be continued without delay.

Nursing progress notes for this resident documented an initial provider visit the day after admission, stating the resident was seen as a new admit and prior to leaving AMA, and that the resident reported being very unhappy with care since admission, including having to wait several hours for pain medication and ice for her knee. The resident, who had documented allergies to codeine and tramadol, stated in interview that she arrived mid-afternoon on the admission date, was on acetaminophen every eight hours due to opioid allergies, and that she had no pain medication available upon arrival despite having a fresh injury. Staff interviews confirmed that staff relied on the MAR for medication administration, that OTC medications were kept on hand so there should not be a lag in providing them, and that hospital discharge orders were to be continued at the facility. A joint record review with the Resident Care Manager showed no documentation of pain medication administration upon admission, and the LPN acknowledged that the acetaminophen should have been given.

For a second resident admitted with a diagnosis including head injury due to a fall, the hospital discharge summary specified that four scalp staples required removal on a specified date. The facility’s Order Summary Report contained a physician order to remove four scalp staples starting on that date, and the December Treatment Administration Record showed the staples marked as removed on that date, with a registered nurse documented as having performed the removal. However, a later hospital Emergency Department record documented a right scalp wound with dried blood and staples in place. In interview, the RN stated she remembered attempting staple removal, that the resident refused and they had to reschedule, and that she believed she removed a couple of staples before the resident told her to stop, but she could not recall the total number removed. Joint record review showed no additional scheduled scalp staple removal treatments or nursing notes documenting further attempts after the initial date, despite the discharge summary specifying four staples and the expectation that all staples would be removed. The DON stated they expected staff to assess for pain, assess the site, and ensure everything was removed, but the records contained no further documentation of staple removal after the initial entry.