Failure to Assess and Manage Pain During Night Shift
Penalty
Summary
A resident with diagnoses including COPD, congestive heart failure, anxiety disorder, and failure to thrive, who was cognitively intact and responsible for their own healthcare decisions, was not assessed for pain or provided pain medication during a specific night shift. The facility's policy required pain assessments and appropriate pain management based on comprehensive assessment and resident choice. The resident had physician orders for as-needed hydrocodone-acetaminophen and acetaminophen for pain, and a specific order for pain assessments every shift for three days. Review of the medical record showed that while pain assessments were documented for all other shifts, there was no pain assessment or administration of pain medication during the night shift in question. The resident later reported to staff that they did not receive pain medication that night, and the Medication Administration Record confirmed that the first dose of pain medication was given the following morning for severe pain. The Director of Nursing confirmed that the resident was not assessed for pain and did not receive pain medication during the identified night shift.