Resident #800's physician had prescribed two different pain medications in April: hydrocodone-acetaminophen tablets for severe pain rated 6-10, and regular acetaminophen for mild pain rated 1-5. The resident consistently reported pain levels that qualified for both medications.
But pharmacy records show no pain medication was ever given.
From May 13 through July 31, the resident reported pain ratings of 5 or 6 during 13 separate wound assessments. On May 13 and May 20, they rated pain at 5. On June 3, June 10, and June 12, the pain increased to 6. The pattern continued through summer, with ratings of 5 on June 17, June 19, and June 24, then back to 6 on July 15, July 22, July 24, and July 31.
The facility's wound nurse was supposed to assess pain weekly and document medication given during wound care treatments. She documented the pain scores but gave no medication.
Assistant Director of Nursing confirmed in an August interview that no medications were administered before wound care treatments, despite the documented pain levels and available prescriptions.
The wound nurse told inspectors she should have completed weekly pain assessments from April 22 through May 13 but didn't verify whether the resident received pain medication during that period either.
Resident #800's care plan from April specifically addressed "alteration in comfort, pain related to pressure ulcers" with interventions including administering pain medications as ordered and observing for breakthrough pain episodes.
The facility's pain management policy, updated in May, requires staff to "assess, monitor, treat and evaluate pain to ensure effective pain management is provided."
Floor nurses completed routine pain assessments every shift, but the wound nurse never followed up after treatments to see if residents still experienced pain or needed additional medication.
On two occasions, staff tried repositioning the resident instead of medication, but never documented whether this helped or if other treatment was needed.
The Assistant Director of Nursing was also responsible for wound care documentation for two other residents. Resident #300 had no pain medication ordered at all, despite receiving similar wound treatments.
The wound nurse acknowledged to inspectors that she failed to verify pain medication administration for Resident #800 throughout the months-long period when pain levels consistently met the criteria for prescribed medications.
State inspectors discovered the pain management failures during a complaint investigation in September. The facility had clear physician orders, documented pain levels that qualified for medication, and a policy requiring effective pain management.
Resident #800 endured months of untreated pressure ulcer pain while their prescribed medications sat unused.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Altercare Thornville Inc. from 2025-09-02 including all violations, facility responses, and corrective action plans.