IDPH has cited and fined Addolorata Villa when the facility failed to follow physician’s orders and adequately manage the resident’s post-surgical pain, resulting in the resident experiencing extreme pain and inability to sleep for an extended period.
The resident in question experienced a mechanical fall during a strength training session. As a result, the resident was emergently transferred to the hospital, where she was diagnosed with a left hip fracture and underwent Open Reduction Internal Fixation (ORIF) surgery.
Three days later the resident was readmitted to the facility with physician’s orders for pain management, including scheduled Acetaminophen and as-needed Tramadol for moderate pain and Oxycodone for severe pain.
During a visit 2 days later, the resident told the state surveyor about her experience upon returning to the facility: “I couldn’t sleep because I was in severe pain, and I could not get the nurse to come in to give me my pain medications. I don’t remember getting anything for my pain when I first got back from the hospital. I did not see a nurse to see how I was doing later that evening.”
The resident’s admission assessment, documented by an RN, indicated that the resident had experienced severe pain over the last five days, which made it hard for her to sleep at night and limited her day-to-day activities.
A review of the resident’s Medication Administration Record (MAR) revealed that on the day that the resident returned to the facility, no pain medications were provided to the resident, including her scheduled Tylenol, and no pain medications were given throughout the evening and early morning the next day. It wasn’t until mid-afternoon of the next day that the resident received her as-needed Tramadol for moderate pain, despite expressing severe pain upon admission.
The Director of Nursing acknowledged that the resident’s initial pain assessment indicated severe pain and that the resident did not receive any pain medications until the following day.
A Nurse Practitioner stated that nurses should assess pain at least every shift, document the location and intensity of the pain, and provide appropriate medication based on the pain rating. The Nurse emphasized that if a patient says they’re in pain, it should be addressed to relieve their discomfort, and post-surgical pain orders should be followed as prescribed.
The facility’s “Pain Management” policy outlines the importance of recognizing, evaluating, and managing pain consistent with the resident’s comprehensive assessment, plan of care, and current professional standards of practice. The policy also states that pain medications should be selected based on pertinent treatment guidelines and that staff should evaluate and report how much and how often the individual asks for as-needed pain medication.
In summary, the facility failed to follow physician’s orders and adequately manage the resident’s post-surgical pain, resulting in the resident experiencing extreme pain and inability to sleep for an extended period.
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