Failure to Obtain Orders for Pain Management at Lower Pain Levels
Penalty
No penalty information released
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Summary
A deficiency was identified when a resident admitted after a fall with multiple fractures, requiring healing and physical therapy, did not have a physician order to address and medicate pain levels below a score of 7. The medical record review showed that the only pain medication order was for Oxycodone 5 mg, 2 tablets every 4 hours as needed for severe pain, defined as a pain score of 7-10. Despite this, the medication administration record indicated that Oxycodone was administered 64 times, including 19 instances for pain scores between 0-6, for which there was no corresponding physician order. This issue was confirmed through review of the resident's records and discussion with the facility's Director of Nursing.