Failure to Follow Pain Medication Parameters and Documentation Standards
Penalty
Summary
The facility failed to ensure safe and appropriate pain management for a resident with multiple rib fractures, specifically in the administration and management of pain-relieving medications. The resident's care plan indicated the need for analgesia as per physician orders, with pain levels to be assessed using a numeric scale. However, the Medication Administration Record showed that acetaminophen, ordered for mild pain (1-3), was administered for higher pain levels (4 and 5) without documented rationale. Additionally, hydrocodone-acetaminophen, a narcotic, was administered for pain levels of 3, despite the absence of specific pain level parameters in the physician's order for this medication. The Director of Nursing confirmed that medications were given outside of the ordered parameters and that there was no documentation explaining the rationale for these decisions. The physician stated that pain level parameters are typically included in orders and that hydrocodone would have been intended for moderate pain (4-6), not mild pain. The facility's pain management policy required consistent assessment, management, and documentation of pain and medication effectiveness, which was not followed in this case.