Failure to Ensure Safe and Appropriate Pain Management and Opioid Monitoring
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with multiple complex medical conditions, including congestive heart failure, COPD, osteoarthritis, and a history of fractures and neoplasm. The resident was on a scheduled pain regimen and received both acetaminophen and oxycodone as needed for pain and discomfort. However, the orders for oxycodone did not specify the type or severity of pain for which it should be administered, and the care plan lacked a focus on opioid use or interventions for monitoring opioid-related side effects. Documentation review revealed that after administration of both acetaminophen and oxycodone, the effectiveness of the medications was frequently recorded as "unknown," with no follow-up pain assessments or evidence of monitoring for adverse effects. This pattern was observed multiple times over two months, with no nursing assessments or documentation to indicate that the resident's pain was re-evaluated or that opioid side effects were monitored as required by facility policy. The care plan only included general interventions for monitoring pain medication effectiveness and notifying the provider if medication was ineffective, but did not address opioid-specific monitoring. Interviews with nursing staff and the DON confirmed that pain reassessment was required after analgesic administration and that "unknown" should not be selected unless the resident was no longer in the facility. Staff also confirmed there was no designated place in the documentation system to record monitoring for opioid side effects, and the care plan should have included such interventions. Facility policy required monitoring for medication effectiveness, adverse effects, and signs of overdose, as well as pain re-evaluation 30 to 60 minutes after administration, but these practices were not followed.