Failure in Pain Management for a Resident
Penalty
Summary
The facility failed to provide effective pain management for Resident 114, who was admitted with a displaced bimalleolar fracture and a history of repeated falls. The facility's policy on pain assessment and management, last reviewed on March 3, 2025, emphasized the use of non-pharmacological interventions either alone or in conjunction with medications to manage pain. However, the facility did not adhere to this policy, as there was no documented evidence of attempts to use non-pharmacological interventions before administering opioid pain medication to the resident. Resident 114 had physician orders for Tramadol HCl 25 mg and later 50 mg to be administered every 4 hours as needed for moderate to severe pain. Despite these orders, the medication was administered multiple times without any documented attempts of non-pharmacological interventions. This occurred on numerous occasions from February 25, 2025, through March 31, 2025, with pain levels reported between 4 and 8. The facility's failure to document attempts of non-pharmacological interventions before administering the medication was confirmed by the Director of Nursing during an interview on April 4, 2025. The deficiency was identified through a review of the resident's clinical records and medication administration records (MAR), which showed repeated instances of opioid administration without adherence to the facility's pain management policy. This lack of documentation and adherence to policy indicates a failure in providing comprehensive pain management for Resident 114, as required by the facility's own guidelines and state regulations.