F0697

G

Failure to Obtain and Administer Ordered Opioid Resulting in Prolonged Pain

Mount Vernon, Illinois Survey Completed on 03-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide timely and effective pain management for a newly admitted resident with multiple right lower extremity fractures. The resident was admitted with a right femur fracture, displaced trimalleolar and bimalleolar fractures of the right lower leg, cellulitis of the right lower limb, and end-stage renal disease. On admission assessment, the resident was cognitively intact, oriented to person, place, time, and situation, and reported a pain level of 8/10 in the right leg. The care planning documentation identified pain as a focus area, with goals and interventions that included administering analgesia per orders, anticipating the resident’s need for pain relief, responding immediately to complaints of pain, monitoring pain characteristics, and notifying the physician if interventions were unsuccessful or if pain represented a significant change.

The resident had an order dated 02/14 for oxycodone 5 mg PO every 4 hours PRN for pain and an order for Tylenol 325 mg, two tablets PO every 4 hours PRN for mild pain starting 02/15. However, the Medication Administration Record shows that oxycodone was not administered until 02/19, while Tylenol was given on several occasions between 02/15 and 02/19 for pain levels ranging from 3 to 5. Vital records document multiple pain scores during this period, including scores of 5 on 02/14 and 02/16, and scores of 3–5 on subsequent days, with a pain score of 7 on 02/19 prior to oxycodone administration. A family member reported that the resident arrived in horrible pain, remained alert and able to state she was in pain, and did not receive oxycodone for approximately two days, during which Tylenol was given but did not relieve the pain.

Staff interviews and pharmacy information show that the facility did not effectively secure the ordered oxycodone or utilize available emergency medication resources in a timely manner. The DON stated the pharmacy was problematic and that oxycodone was not in the emergency medication bank, and also stated she did not know why staff did not call her when they had difficulty obtaining the medication. The ADON and agency LPN described attempts to contact the pharmacy and confusion about whether oxycodone was available in the emergency medication bank, with the agency LPN reporting she lacked access to the bank and only had Tylenol to give despite the resident being in significant pain. A staff RN reported calling the pharmacy and providers multiple times on 02/16, stated the resident was in a lot of pain and crying with pain rated 10/10, and believed there was no excuse for not trying to obtain pain medication over the weekend. In contrast, the pharmacy and emergency medication bank representatives stated that oxycodone 5 mg IR was stocked in the emergency medication bank, that no emergency run or emergency bank access was requested by facility staff, and that an active prescription for oxycodone was not received until 02/16, with the medication delivered on 02/17. CNAs reported the resident frequently yelled out and appeared to be in a lot of pain, especially with repositioning, while nurses lacked the ordered pain medication and relied on repositioning and Tylenol, which only helped somewhat or not much at all. The facility’s own pain management policy states its purpose is to effectively manage pain to remove adverse physiologic effects of unrelieved pain and promote comfort, but the documented actions and omissions resulted in prolonged, significant pain for this resident due to the unavailability and delayed provision of the ordered oxycodone.