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.
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.
A resident with severe pain from neuropathy, recent surgery, and pressure ulcers did not receive prescribed pain medication due to staff inaction and lack of access to the automated drug dispensing system. CNAs reported the resident's pain to an agency nurse, who did not administer the medication or notify facility leadership, resulting in unmanaged pain until the next shift. The facility's pain management procedures were not followed, and the physician was not informed of the issue.
A resident with chronic pain did not receive prescribed oxycodone as ordered on multiple occasions due to delays in medication reordering and pharmacy delivery. Staff documented medication unavailability and offered alternative interventions, which the resident refused. The resident experienced severe pain, resulting in repeated calls to EMS and hospital transfers for pain relief. Facility staff and leadership acknowledged issues with medication ordering processes and communication, leading to lapses in pain management.
A resident with chronic pain and a history of kidney disease did not receive prescribed PRN tramadol before dialysis due to LPNs and a CMT lacking access to the medication dispensing system and EMR. Despite reporting severe pain, only acetaminophen was administered, and staff did not notify management or the physician about the inability to provide the ordered medication. Documentation of the resident's pain and actions taken was incomplete, and leadership was unaware of the access issue until after the incident.
A resident admitted after knee replacement surgery experienced moderate pain that was not addressed in a timely manner due to delays in obtaining and administering prescribed pain medications. Staff failed to document administration of pain medication and did not notify the physician when pain increased, despite ongoing pain assessments and facility policies requiring prompt pain management.
A resident with severe back pain and multiple comorbidities did not receive a physician-ordered opioid pain medication due to staff failing to transcribe and process the order. Instead, the resident was intermittently given Tylenol, which was reported as ineffective. Staff interviews revealed a lack of awareness of the opioid order, and the order was never sent to the pharmacy, resulting in inadequate pain management.
A resident with chronic conditions experienced ongoing, unrelieved pain due to the facility's failure to consistently assess, monitor, document, and address pain, as well as to notify the physician when pain was not controlled by PRN acetaminophen. Staff did not update the care plan to reflect pain management needs, and the physician was not informed of acute changes, resulting in the resident experiencing increased pain without appropriate intervention.
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