Failure to Assess Pain and Provide Non-Pharmacological Interventions Prior to Pain Medication Administration
Penalty
Summary
The facility failed to provide adequate and appropriate pain management for a resident with moderate cognitive impairment who required such services. Specifically, staff did not ensure an accurate pain level was assessed and documented prior to administering pain medication on at least one occasion, as evidenced by the administration of tramadol when the pain level was documented as "0". Additionally, the medical record did not show that non-pharmacological interventions were provided prior to administering pain medication on multiple occasions when the resident reported moderate to severe pain levels. Review of the facility's pain management policy indicated that staff should use appropriate pain assessment tools and implement non-pharmacological interventions before administering medication. However, documentation for the resident showed repeated instances where these steps were not followed. Both the RN and DON confirmed that pain assessments and non-pharmacological interventions should have been completed and documented prior to medication administration, but this was not consistently done for the resident in question.
Plan Of Correction
F 697 Pain management • How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Pain assessment on resident 49 was done on 6/23/25 by ADON. The resident had a pain level of 7/10 on 6/22/25 at 1535 and she was given Tramadol which was effective. Follow-up pain level was 0/10. Documentation of non-pharmacological intervention was initiated on 6/17/25 by the charge nurse. 1:1 training with LVN who made the error was done on 6/23/25 by ADON on pain management and providing non-pharmacological interventions prior to administration of medication. Inservice with licensed nurses on pain management and providing non-pharmacological interventions prior to administration of medication initiated on 6/23/25 by DON/Designee and will be completed by 7/10/25. • How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. An audit of all residents with tramadol was done by the DON/designee on 7/3/25. We found 2 other residents on tramadol, no errors were found with the pain assessment and non-pharmacological interventions were attempted prior to administration of medication. • What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur. Medical records director/designee will conduct an audit of residents on tramadol to check if non-pharmacological interventions were provided prior to administration of medications. Medical records director/designee will also validate if the initial pain level is being documented. These audits will be done 3x/week x 3 months. Any significant findings will be reported to DON/designee for follow-up. • How the facility plans to monitor its performance to make sure that solutions are sustained. The POC is integrated into the QA system. The IP/designee will provide a summary trend analysis of the findings to the facility's monthly QAPI Committee x 3 months or until such time consistent substantial compliance has been achieved as determined by the committee. Date of compliance: 7/10/25 F 697