Failure to Provide and Document Appropriate Pain Management
Penalty
Summary
The facility failed to provide appropriate pain management for one resident by not accurately documenting pain assessments and not administering pain medication according to the physician's orders. Specifically, the medical record review showed that the resident was given oxycodone, a narcotic opioid, even when the documented pain level was zero, which was outside the ordered parameters that required administration only for moderate to severe pain (pain levels 6-10). Additionally, pain assessments were not consistently documented each shift as required, and there were discrepancies between the administration of pain medication and the recorded pain levels. The facility also did not ensure that non-pharmacological interventions were implemented and documented prior to administering pain medication, as required by both physician orders and facility policy. On several occasions, the non-pharmacological interventions were either not documented or were marked as 'none' before the administration of oxycodone. This was confirmed through review of the Medication Administration Record (MAR) and interviews with both the LVN and the DON, who acknowledged that non-pharmacological interventions should have been attempted and documented prior to medication administration. Interviews with facility staff, including the LVN and DON, confirmed that the expected process was not followed. Both staff members verified that pain medication should not be administered when the pain level is documented as zero, and that non-pharmacological interventions should not be marked as 'none' if pain medication is given. The DON also stated that pain assessments should be accurately documented each shift and updated if the resident's pain status changes after initial documentation.