Failure to Document Pain Assessment and Medication Administration
Penalty
Summary
The facility failed to ensure that pain assessments were conducted and documented before and after the administration of pain medication for one patient. Specifically, a licensed nurse did not sign the Medication Administration Record (MAR) after removing Norco, a controlled pain medication, from the medication cart and signing the Controlled Drug Record (CDR) for two separate instances. This omission resulted in no documentation of pain assessment at the time the medication was administered. The patient involved had a diagnosis of chronic pain syndrome and was moderately impaired in cognition, requiring assistance with daily activities. Physician's orders indicated that Norco was to be administered as needed for severe pain, and the CDR showed that the medication was removed and presumably given on two occasions. However, the MAR for those dates did not reflect any pain assessment or documentation of medication administration. During interviews, both the nurse involved and the Director of Nursing confirmed that the process requires signing the MAR after administering medication to document pain levels and effectiveness. Facility policies also require pain assessment and documentation in conjunction with medication administration. The lack of documentation on the MAR meant that there was no record of pain assessment or reassessment for the patient during those times.
Plan Of Correction
A029: 1254.7(b) Health & Safety Code 1254 Corrective action for resident found to have been affected by this deficiency. On 3/11/2025, DON provided 1:1 in-servicing to LVN 4 regarding proper PRN controlled medication administration documentation and accountability. On 3/11/2025, RN assessed Patient 9's pain to ensure pain was well managed. Identify any other residents who may have been affected by the deficient practice. On 3/12/2025, MRD audited the last 7 days of PRN Norco administration for in-house patients to ensure all documentation is complete. There were none other issues identified. On 3/12/2025, MRD performed an audit of the last 7 days of PRN Norco administration for in-house patients to ascertain if their pain levels were documented at the time of PRN medication administration. There were none other issues identified. Measures that will be put into place to ensure that this deficiency does not recur: Beginning 3/11/2025, DSD initiated in-servicing for licensed nursing regarding pain assessment, proper documentation, and signing for administration of controlled medications. Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur: Beginning 3/12/2025, MRD will perform weekly audits of the last 7 days of PRN Norco administration for in-house patients to ensure all documentation is complete and that pain has been assessed. These audits will continue for 1 month or until substantial compliance is obtained. Any ongoing issues will be reported by MRD at the monthly QA meeting. Date of corrective action would be completed: 04/03/25