Failure to Complete Pain Assessments After PRN Narcotic Administration
Penalty
Summary
The facility failed to complete required pain assessments for a resident with a history of squamous cell carcinoma of the skin and dementia, who had a physician's order for hydrocodone-acetaminophen to be administered as needed for moderate to severe pain. Despite documented administration of this narcotic pain medication on multiple occasions, there was no corresponding documentation in the Electronic Medication Administration Record (EMAR) of the medication being given, nor were pain assessments completed to evaluate the effectiveness of the medication. The plan of care for the resident specifically included interventions to document the effectiveness of PRN pain medications, but these were not followed. Interviews with the Director of Nursing revealed that the facility's process required a Qualified Medication Aide (QMA) to report the need for PRN pain medication to a nurse, who would then authorize administration, ensure documentation in the EMAR, and complete a follow-up pain assessment. However, the QMA failed to document the administration in the EMAR, which prevented the nurse from being prompted to perform the required pain assessment. As a result, no pain assessments were completed for the resident on the dates when the medication was administered, contrary to facility policy and the resident's care plan.