A resident with a left femur fracture and left hip replacement did not receive timely pain medication as ordered, and pain documentation was incomplete during the overnight shift. The resident reported worsening leg pain, said medication had been delayed for hours, and law enforcement had to assist before the LPN gave Tylenol. Later, the resident had a pain score of 7 and was sent to the hospital after an x-ray showed the hip replacement was dislocated.
The facility failed to timely reorder and provide ordered pain medications for two residents with chronic pain, resulting in multiple missed doses of methadone and pregabalin (Lyrica). One resident with a history of opioid abuse and PTSD went three days without methadone, with MAR entries showing the drug as “on order” or “awaiting pharmacy delivery,” while the resident reported pain, irritability, sweating, and feeling they were going into withdrawal. Another resident with osteoarthritis and back pain missed several scheduled doses of Lyrica over multiple days, with MAR notes again indicating the medication was “on order.” The residents reported lying in pain and going days without medications, and staff interviews revealed delays related to obtaining new prescriptions and failures to utilize available backup medication.
A resident with intact cognition and an infected tooth had repeated reports of severe mouth/jaw pain, but ordered antibiotics were missed and the opioid pain medication was discontinued despite ongoing 10/10 pain. Dental services documented decayed teeth and recommended extraction plus antibiotics, yet the resident continued to report pain and there were no notes showing the MD was contacted about the excessive pain. The DON acknowledged the missed doses and uncertainty about why the pain medication was stopped.
Inadequate pain management for a resident with severe right hip pain was identified after he was observed grimacing, moaning, and rating his pain as 8/10 while trying to reposition for relief. The resident believed his oxycodone was scheduled rather than PRN, and staff reported he had declined therapy related to pain, could not reposition himself, and required extensive assistance with care due to ongoing pain.
A hospice resident with CREST Syndrome Scleroderma and Rheumatoid Arthritis, who was cognitively intact, reported waking in severe morning pain and stated they wanted to be awakened for nighttime pain medication. Review of the care plan and orders showed scheduled morphine every four hours plus PRN dosing for breakthrough pain, but the MAR documented multiple missed midnight doses, with nursing staff recording that the medication was not given because the resident was sleeping. The UM and DON confirmed the doses were not administered despite orders and policies requiring pain management consistent with the resident’s care plan and expressed preferences.
A resident with multiple chronic conditions and full cognitive abilities reported that pain medication was not available on arrival and that she waited over 24 hours for relief, with Tylenol ineffective and repeated requests for pain treatment. Records showed the first pain medication was not administered until about 28 hours after admission, despite prior facility records showing she had been receiving Tramadol before transfer, and the pain care plan only addressed observing and reporting pain rather than including pain treatment interventions.
A resident with osteomyelitis, pressure ulcers, diabetes, morbid obesity, and chronic pain experienced severe pain during transfers and bed positioning, but his care plan did not include specific transfer or positioning instructions. He reported that improper placement in bed worsened tailbone pain and that movement caused extreme pain, while the MAR showed multiple missed PRN doses of hydrocodone-acetaminophen and the DON confirmed the facility had not met with him about his pain concerns.
The facility failed to ensure safe, consistent pain management and proper controlled drug administration for multiple residents. A cognitively intact resident with chronic pain conditions reported not receiving scheduled hydromorphone and methocarbamol from an agency LPN, despite MAR and narcotic records indicating administration, and described increased pain afterward. The LPN admitted to locking narcotic keys in the med room, pre‑prepping narcotics, and not properly documenting medications, while a regional clinical nurse and another nurse observed poor adherence to controlled substance count procedures. Record review for other residents showed missed or undocumented doses of hydrocodone‑acetaminophen and pregabalin, with discrepancies between Proof of Use forms and MARs and no explanations for withheld doses. During a resident group meeting, several residents reported late or missed scheduled and PRN pain medications, confrontational responses from staff when concerns were raised, and having to attend therapy without timely PRN pain control, particularly citing problems with a male nurse who was no longer employed.
A resident with chronic pain syndrome, cancer, and intact cognition sustained a fall, striking the lower back on the bed frame and developing a large, very tender hematoma. Despite physician orders allowing ice then heat and later ordering warm compresses and scheduled oxycodone, staff delayed initiating non-pharmacological interventions, missed multiple ordered warm compress treatments, and failed to administer several scheduled oxycodone doses without documenting reasons. Pain assessments documented frequent, severe pain that interfered with sleep, rehab, and daily activities, and the resident reported staying in bed and becoming incontinent due to pain and fear of getting up. The DON and RN staff acknowledged delays in treatment and that increased pain was not communicated to the physician, while an x-ray later showed an L1 compression fracture associated with post-fall pain.
Failure to provide timely pain management after falls with fractures. Two residents with significant cognitive and medical histories were found after falls and later shown to have femur fractures requiring surgery. One resident developed escalating pain with grimacing, crying out, and an externally rotated leg, yet remained in the facility for about 31 hours with no documented pain meds or non-pharm interventions before transfer. Another resident reported hip and knee pain rated 8/10, had x-ray findings suspicious for fracture, and also had no documented pain relief before being sent out after about 12 hours.
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