Failure to Consistently Follow Pain Management Policy
Penalty
Summary
A deficiency occurred when the facility failed to follow its own pain management policy and procedure for a resident with chronic pain. The resident reported that, two weeks prior, a nurse instructed her to take a different medication instead of her regular pain medication, resulting in her experiencing significant discomfort for several hours without her usual pain relief. Review of the resident's physician orders indicated that Oxycodone HCL was prescribed for moderate pain and Acetaminophen for mild pain, with specific dosing instructions. However, the medication administration record showed that the resident received Acetaminophen on two occasions, despite her chronic pain status and the lack of explanation from the Assistant Director of Nursing (ADON) for this change in medication. The facility's pain management policy required collaboration among healthcare professionals and the resident to develop and implement appropriate pain interventions, as well as ongoing monitoring and revision as needed. The observed inconsistency in administering the prescribed pain medication, and the lack of documentation or rationale for substituting Acetaminophen for Oxycodone, led to the resident's pain not being consistently managed according to the established policy.