The incident at Glenburnie Rehab & Nursing Center occurred when the resident, identified as Resident #2, complained of bilateral knee pain and specifically requested Oxycodone at 11:57 p.m. The nurse on duty wrote in progress notes that the resident was asking for the medication but explained "it was no longer on her current medication list."
The nurse updated a communication book requesting the medical doctor review medications and add Oxycodone back "if appropriate." But no immediate intervention followed to address the resident's severe pain.
Resident #2 had been admitted with a history of fractures in her left hip and right leg, along with recent surgical wounds on both knees. During multiple observations over several days, she consistently reported knee pain to inspectors, saying staff usually treated her pain effectively but that she had experienced severe episodes once or twice when medication didn't help.
The facility's own unit manager acknowledged the failure during interviews with federal inspectors. Licensed Practical Nurse #1 reviewed the resident's progress note and stated that with 10 out of 10 pain reported, "the nurse should have called the on-call physician and obtained an order for a pain medication that could be administered immediately."
"The resident should not have been left without any medication until the resident could be seen by the physician or NP," the unit manager said. "At 10/10, we need to get the on-call doctor on the phone."
She could not explain why neither the physician nor nurse practitioner ever addressed the severe pain complaint.
An as-needed order for Oxycodone wasn't added to the resident's medication regimen until 6:45 p.m. the following day — nearly 19 hours after the resident's initial complaint of severe pain.
The attending nurse practitioner, identified as Administrative Staff Member #5, told inspectors she assumed the Oxycodone "fell off the resident's medication list because the order expired as an as needed medication." She said she didn't remember anything being written in the physician concern book about the resident having 10 out of 10 knee pain.
Even she acknowledged the failure: "I would hope that the nurse would have called the physician on call to get an order for a pain medication that could be administered immediately."
Progress notes showed no evidence that either the nurse practitioner or attending physician was ever made aware of the resident's specific report of severe pain that night. The unit manager noted that even if the pain complaint had been listed in the physician's book for the next visit, "this concern should have been passed along in the shift to shift nursing report."
The facility's own pain management policy requires staff to "initiate a pain assessment any time a patient experiences pain that is not usual for the patient." Despite this policy, no assessment was documented following the resident's severe pain complaint.
Federal inspectors observed the resident on multiple occasions over several days, finding her alert and conversational each time. During each observation, she reported ongoing knee pain but noted that staff usually managed it effectively, except for the severe episodes when medication provided no relief.
The violation represents a failure to provide safe and appropriate pain management for residents who require such services. Inspectors classified the incident as causing minimal harm or potential for actual harm.
The administrator and director of nursing were informed of the concerns during the inspection but provided no additional information before inspectors completed their review.
The case highlights a critical gap between policy and practice at the Richmond facility, where staff failed to follow their own protocols for addressing severe resident pain and left a post-surgical patient to suffer through the night without appropriate medical intervention.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Glenburnie Rehab & Nursing Center from 2025-10-29 including all violations, facility responses, and corrective action plans.
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