Failure to Document and Implement Comprehensive Pain Management Practices
Penalty
Summary
The facility failed to ensure professional practice standards related to pain management for one resident with chronic back pain. According to the facility's pain management policy, staff are required to assess and document pain characteristics such as onset, duration, location, severity, alleviating and aggravating factors, possible causes, and accompanying symptoms. The policy also requires that non-pharmacological interventions be attempted prior to administering PRN analgesics, with all interventions and their effectiveness documented. However, review of the resident's records showed that these standards were not followed. The resident, who was admitted with chronic back pain, reported frequent pain and had physician orders for both Tylenol and Percocet to be given as needed for pain. The medication administration records indicated that while Tylenol was not administered, Percocet was given multiple times over several days. Each administration of Percocet lacked documentation of the required pain assessment elements, including pain onset, duration, location, severity, and related factors. There was also no documentation of any non-pharmacological interventions being attempted prior to medication administration, as required by facility policy. Interviews with facility staff, including the Director of Nursing, confirmed that pain location, pain scale, and non-pharmacological interventions should be included in physician orders and documented in the resident's records. The Director of Nursing acknowledged that these standards were not met for this resident, as the orders and documentation did not include the necessary pain assessment details or evidence of non-pharmacological interventions. The deficiency was cited under multiple state regulations related to medical director oversight, pharmacy services, resident care policies, and nursing services.