F0697

D

Failure to Administer Ordered Pain Medications and Monitor Pain

Artesia, New Mexico Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The facility failed to provide safe and appropriate pain management for a resident with multiple complex medical and psychiatric diagnoses, including schizophrenia, bipolar disorder, bacteremia, syphilis, multidrug-resistant pseudomonas infection, and a third-degree burn of the left lower limb. Physician orders dated 02/17/26 included Suboxone 8-2 mg sublingual film three times daily for opioid use disorder, Oxycodone 15 mg by mouth every four hours as needed for moderate pain, and Tylenol 325 mg, two tablets by mouth every six hours as needed for pain or fever. The Medication Administration Record for February 2026 showed that Suboxone was not administered for four days (02/17/26 through 02/20/26) because the medication was not available in the facility, and there was no administration of either Oxycodone or Tylenol during this period. There was also no documentation of any pain level on the MAR.

The resident’s baseline care plan dated 02/17/26 documented that the resident’s pain was constant with a pain level of five, but the care plan did not include any instructions or indications related to pain management. During an interview, the resident reported that his pain was usually at a level ten on a 0–10 pain scale. In a subsequent interview, the DON confirmed that the resident did not receive Suboxone as ordered due to unavailability, did not receive Oxycodone or Tylenol during the days Suboxone was unavailable, and that the resident’s pain level was not monitored during those days because pain monitoring had not been done for this resident. The DON further confirmed that the resident did not have pain monitoring in place and did not have a care plan that included instructions and interventions for pain management, despite the need for such measures.