Omissions in Pain Management Documentation
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive care plan for pain management. Specifically, there were multiple omissions in the medication and treatment administration records for medications and treatments related to pain management for a resident. The resident, who was admitted with diagnoses including pain, had a comprehensive care plan that documented potential and intermittent pain related to activity level, with instructions to monitor for pain, administer medication as ordered, and monitor the effectiveness of medications. However, the Treatment Administration Record showed omissions for a prescribed cream on several dates, and the Medication Administration Record also had omissions for other pain medications, with no documented evidence explaining the reasons for these omissions. During interviews, the resident expressed experiencing pain and stated that they had received some pain medication but were still in pain. The resident later mentioned that their pain management was overall effective with the prescribed medications but believed they were in pain due to overexertion in therapy. The Registered Nurse Unit Manager acknowledged the omissions and stated that the medication nurse should have documented the reasons for not administering the medications. The Director of Nursing confirmed the expectation of no omissions in the medication or treatment administration records and stated that if a medication was not administered, the reason should be documented.
Plan Of Correction
Plan of Correction: Approved February 28, 2025 F684 Ss=D The Plan of Correction is submitted in compliance with applicable law and regulation. To demonstrate continuing compliance with applicable law, the center has taken or will take actions set forth in following alleged deficiency. How corrective actions will be accomplished for residents found to have been affected by deficient practice: 1. Nurse manager #10 and the nursing staff on unit where resident #15 resides received education on medication administration, ensuring all medications are signed for in MAR/TAR and no omissions present, Date 2/25/25. Resident #15 was discharged from facility on 2/20/25, no issues related to noted omissions found. All residents have the potential to be affected by this practice - All residents MAR/TAR were audited on 2/25/25 for omissions, no occurrences found. Measures put in place or systemic changes made to ensure that the deficient practice will not reoccur: - The Policy titled medication administration dated 4/20/21 was reviewed by Director of Nursing and Administrator on 2/25/25, with no revisions needed. - The director of nursing/designee will educate all nursing staff on medication administration, ensuring all medications are signed for in MAR/TAR and no omissions present. How facility plans to monitor performance to make sure the solutions are sustained: To ascertain the effectiveness of the education and audit was developed. The Director of Nursing/Designee will perform an Audit for medication administration 5 times per week for random shift to check for omissions x 3 months. Any discrepancies will be immediately corrected and staff re-educated and/or counseled as needed. The results of the Audit will be reported at monthly QAPI.