Inaccurate Documentation of Pain Assessment and Controlled Medication Administration
Penalty
Summary
The facility failed to accurately document a pain assessment result and the administration of a controlled pain medication for a resident with a diagnosis that included cellulitis of the right leg. Physician orders specified that one tablet of oxycodone was to be given for moderate pain (level 4-6) and two tablets for severe pain (level 7-10). On a specific date and time, the Controlled Drug Record showed that two tablets of oxycodone were removed from the medication cart by a licensed nurse, but the Medication Administration Record (MAR) indicated that only one tablet was administered and documented a pain level of 4/10. During interviews, the licensed nurse confirmed that two tablets were actually administered for a pain level of 7, and acknowledged that the MAR documentation was incorrect. The Director of Nursing also stated that pain assessment and medication administration should have been documented accurately. The facility's policy requires an accurate account of resident care and status in the clinical record, which was not followed in this instance.