Failure to Document Pain Levels for Pain Medication Administration
Penalty
Summary
The facility failed to provide the highest practicable care regarding physician-ordered pain medications for a resident, identified as Resident 108. The clinical record review revealed that the resident had physician orders for Oxycodone 5 mg, 2 tablets by mouth every 4 hours as needed for severe pain rated between 7 to 10. However, the medication administration record (MAR) for February and March 2025 showed that staff did not document the resident's pain level on multiple occasions when the medication was administered. This lack of documentation occurred on several dates and times, indicating a failure to adhere to the physician's orders regarding pain management. The deficiency was identified during a review of the resident's clinical records and was confirmed in an interview with the Director of Nursing. The report highlights that the staff did not administer the pain medications according to the physician-ordered pain scale levels, which is a requirement under the facility's pain management protocols. This oversight was previously cited in a survey conducted on May 23, 2024, indicating a recurring issue with the facility's compliance with pain management standards.