Failure to Document Pain Assessments and Non-Pharmacological Interventions
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with significant medical conditions, including cerebral infarction, aphasia, and hemiplegia. The resident was nonverbal and unable to request pain medication independently. Physician orders were in place to monitor pain every shift and to administer oxycodone as needed for moderate to severe pain, and acetaminophen as needed for mild pain. The care plan included the use of non-pharmacological interventions and required pain assessments upon admission, quarterly, with significant changes, and as needed. However, the clinical record did not document the use of non-pharmacological interventions, nor did it consistently record pain levels prior to the administration of as-needed pain medication. Medication Administration Records (MAR) and Controlled Drug Administration Records showed that oxycodone was administered multiple times, but there was a lack of documentation regarding the resident's pain level before administration and the effectiveness of the medication after administration, except for a few instances. There was also no documentation that acetaminophen was ever administered. The care plan interventions, such as repositioning, diversional activities, and other non-pharmacological measures, were not documented as being attempted prior to administering narcotic pain medication. Interviews with the resident's family member and nursing staff revealed that the family had requested scheduled pain medication due to the resident's inability to verbalize pain, and had observed nonverbal signs of pain such as lip biting, grimacing, and tensing up. The staff indicated they relied on family input and observation of facial expressions to assess pain. Despite these observations and requests, the facility did not document the required pain assessments or non-pharmacological interventions, leading to a deficiency in pain management practices for the resident.