Failure to Timely Reassess Pain After Administration of Pain Medication
Penalty
Summary
The facility failed to provide effective pain management for one resident by not reassessing the resident's pain in a timely manner after administering Hydrocodone-Acetaminophen (Norco) on two separate occasions. On one occasion, the nurse reassessed the resident's pain approximately five hours after medication administration, rather than within the expected timeframe. On another occasion, there was no documentation that the resident's pain was reassessed at all after receiving the medication. The facility's policy required pain to be reassessed and documented with adequate detail to gauge the effectiveness of interventions. The resident involved had diagnoses including metabolic encephalopathy and type 2 diabetes mellitus, and was cognitively intact, requiring some assistance with activities of daily living. The resident reported receiving pain medication but stated that no nurse returned to check if the medication was effective. Review of the medical record and interviews with the Director of Nursing confirmed that pain reassessment was either delayed or not documented, contrary to facility policy.