Failure in Pain Management for a Resident
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as Resident R148, consistent with professional standards of practice. The resident, who was admitted with diagnoses including spinal stenosis, low back pain, and chronic pain syndrome, had documented severe pain levels of 10 and 8 on March 3 and March 4, 2025, respectively. Despite having physician orders for Oxycodone and Tramadol for severe and moderate pain, the resident did not receive the prescribed Oxycodone on these dates. Additionally, there was no documented rationale for not administering the medication, nor was there evidence that the physician was informed of the non-administration or that non-pharmacological pain management techniques were implemented. The facility's policy on pain management emphasizes the importance of assessing and addressing pain based on professional standards and the resident's care plan. However, the review of Resident R148's clinical records revealed a lack of adherence to these guidelines. The resident's allergies to several opioids, including Oxycodone, were noted, yet there was no documentation explaining the decision not to administer the prescribed medication or any alternative strategies employed. This oversight in pain management was further highlighted by the absence of documentation regarding the effectiveness of interventions or modifications to the care plan, as required by the facility's policy.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident R148's pain medication were delivered and she has been receiving it as per Physician orders. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: An audit will be conducted of residents that have an order for pain medications to ensure that they are being given per physician order. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Education will be provided by the DON/ and or designee to nursing staff regarding the components of this regulation. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Random audits will be conducted weekly by the DON/ and or designee of five clinical records to ensure that pain medications are in place and are being given as ordered. Audits will be conducted weekly x for four weeks and then monthly for two months. Results of these audits will be reported to the monthly Quality Assurance Performance Improvement Committee until monthly and/or substantial compliance is met. Adjustments to the plan of corrections will be made by the Interdisciplinary team as needed.