Failure to Reassess Pain After Opioid Administration
Penalty
Summary
The facility failed to ensure that residents who received opioid pain medications were re-evaluated for pain within 30 to 60 minutes following administration, as required by facility policy. Record reviews and interviews revealed that for 11 residents with various complex medical conditions—including cerebral palsy, hemiplegia, anxiety disorder, PTSD, neurogenic bladder, heart failure, depression, renal insufficiency, anemia, peripheral vascular disease, multiple sclerosis, dementia, schizophrenia, seizure disorder, cellulitis, chronic pain, arthritis, and paraplegia—there was no documentation of pain reassessment after opioid administration. The number of missed reassessments ranged from two to 62 instances per resident during the review period. The residents involved were prescribed and administered different opioid medications such as hydrocodone-acetaminophen, Norco, oxycodone, Tylenol-Codeine #3, Percocet, Endocet, and Dilaudid, all on an as-needed basis for pain management. Despite the administration of these medications, the clinical records and electronic medication administration records (eMAR) lacked evidence that nursing staff performed or documented pain reassessments within the specified timeframe after each dose. During an interview, the DON confirmed that the facility's policy required nurses to perform pain reassessments within 30 to 60 minutes after administering pain medications. The facility's written policy and referenced clinical guidelines also supported this requirement. However, the documentation review showed consistent noncompliance with this standard for the identified residents.