A facility failed to manage pain effectively for two residents. One resident with cancer and fractures had repeated severe pain, inconsistent reassessment after PRN opioids, gaps in oxycodone availability, and no documented physician notification when pain remained uncontrolled; staff also documented PRN doses that were not supported by the MAR. Another resident with a left ankle fracture did not receive scheduled acetaminophen within the ordered timeframe, and records showed late doses, missing pain assessments, and missing effectiveness documentation.
Two residents did not receive adequate pain management in line with facility policy. One resident was admitted with a pelvic fracture and hospital discharge orders for multiple pain medications, yet no pharmacologic or non‑pharmacologic pain interventions were administered for many hours after admission, despite documented escalating pain up to 10/10 and descriptions of excruciating pain overnight. Medication orders for acetaminophen, hydromorphone, cyclobenzaprine, and gabapentin were present, but the MAR showed they were not given as ordered, and staff interviews revealed confusion about eKit use, lack of signed narcotic scripts, and failure to secure timely pain control. Another resident with a coccyx pressure ulcer reported significant pain during transfers and wound care, frequently yelling and moaning, while the care plan did not address wound‑related pain and PRN acetaminophen was never administered over multiple opportunities, with hydrocodone‑acetaminophen given inconsistently. CNAs and a CMT reported relaying pain complaints to nursing, but were unsure if pain medications were provided, and wound care had to be stopped due to uncontrolled pain.
Delayed pain medication administration for two residents occurred when a CMT did not promptly notify the nurse or ADON that the residents were waiting for PRN oxycodone. One resident with osteomyelitis and post-surgical aftercare reported 10/10 pain, and another resident with psychiatric diagnoses and left hip pain reported 8/10 pain; both said staff were late with pain medication all the time. An LPN later gave the medications about two hours after the requests, and the DON stated this delay was unacceptable.
A resident with multiple sclerosis, a left tibia fracture, and a history of chronic pain had a standing order for scheduled oxycodone every four hours, but after a pharmacy change the facility failed to administer the ordered opioid for four days because the medication was not in stock and new prescriptions had not been processed. MAR entries and nursing notes documented repeated missed doses and ongoing unavailability of the drug, while the resident reported significant pain and was observed crying and overwhelmed. Staff acknowledged the pharmacy transition issues, reported giving only PRN acetaminophen and anxiety medication, and leadership confirmed that the resident should not have been without the ordered pain medication for that length of time.
A resident with chronic low back pain, anxiety, depression, and schizophrenia had a care plan for pain that included medication administration, monitoring, and referral to pain management, but the facility did not follow through on key physician orders and referrals. Although imaging and a pain management consult were ordered and the resident requested stronger pain medication after reporting inadequate relief, the record showed no completed MRI, no documented pain management consult, and no documented alternative pain interventions after the guardian declined a Tramadol increase and requested pain management instead. The facility also lacked policies and procedures for implementing physician referrals and orders and for obtaining informed consent before changing medication regimens.
A resident with a fibula fracture and ongoing severe pain had repeated gaps in pain management documentation and follow-up. Staff did not update the care plan for pain, did not consistently document whether 1 or 2 tabs of hydrocodone-acetaminophen were given, did not always recheck pain after administration, and did not document physician notification when pain remained unrelieved or when Belbuca was unavailable. The resident reported frequent 8/10 to 10/10 pain, delayed response to the call light, and lack of follow-up after PRN pain meds.
Pain Assessment, Documentation, and Care Plan Failures: A resident with chronic left hip pain, low back pain, and arthritis had repeated pain screenings documented as no pain, while the resident reported daily pain that limited getting out of bed and sitting up. Staff did not accurately document pain levels, did not document follow-up after a change in pain medication that led to PRN tramadol, and did not update the pain care plan to include the new medication or resident-specific pain interventions.
Failure to report and manage resident pain: A resident with multiple chronic conditions, including stroke, hemiplegia, PVD, and aphasia, cried out and verbalized pain during personal care and transfer, with facial grimacing and moaning noted throughout the interaction. Two CNAs continued care and transferred the resident with a Hoyer lift without notifying the nurse, and the resident did not receive documented PRN pain medication. Interviews with the ADON, LPN, CNA, resident, and DON confirmed staff expected pain complaints to be reported and assessed, but that did not occur.
A resident who was normally independent with transfers and ambulation was found unable to stand or walk and complained of leg pain, but the RN did not assess the resident, check vitals, contact the MD, or give PRN pain medication during the day shift. The resident was later found with swelling, bruising, and pain, was sent to the hospital, and was diagnosed with a wrist fracture and an L2 compression fracture.
Failure to provide appropriate pain management for a nonverbal resident with chronic pain, severe dementia, and sacral/coccyx wounds. The resident repeatedly moaned, grimaced, and resisted during incontinent and wound care, including waiting while on his/her side for wound care to begin. Staff said they believed the resident was in pain, but the DON said she had not been aware of the pain and staff were not aware the PRN hydrocodone/APAP could be given before care.
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