Failure to Document Nonpharmacological Pain Management Interventions
Penalty
Summary
Facility staff failed to document or initiate nonpharmacological pain management interventions for a resident who had an order for as-needed acetaminophen for mild pain. The resident's care plan identified a potential for altered comfort due to acute illness and chronic morbidities, with interventions including administration of analgesic medication as ordered and regular pain assessments. However, there was no documentation of nonpharmacological pain interventions on the care plan, Medication Administration Record (MAR), or Treatment Administration Record (TAR). During interviews, both the Unit Manager and the Director of Nursing confirmed that nonpharmacological pain interventions were not documented in the resident's medical record, acknowledging that this documentation should have been present. The absence of this documentation meant there was no way to validate that nonpharmacological measures were considered or attempted prior to administering pain medication.