Failure to Follow Pain Assessment and Monitoring Protocols for Residents Receiving Opioid Pain Medications
Penalty
Summary
The facility failed to provide safe and appropriate pain management for two residents by not adhering to physician orders and facility policies regarding pain assessment and monitoring. For one resident with a history of lumbar spinal fusion, low back pain, and end-stage renal disease, the care plan required administration of oxycodone as needed, with pain reassessment within one hour after administration. However, medication administration records showed that pain was not reassessed within the required timeframe, with follow-up assessments occurring more than one to five hours after medication was given. Both the registered nurse and the director of nursing confirmed that the facility's protocol and policy required pain reassessment within one hour, and acknowledged that this was not done as required. For another resident with multiple fractures, respiratory failure, and a history of falls, physician orders and the care plan required pain assessment and documentation every shift, as well as assessment of respiratory rate prior to administering hydromorphone. Medication administration records indicated that pain levels and respiratory rates were not consistently assessed or documented prior to medication administration on several occasions. Interviews with nursing staff and the director of nursing confirmed that these assessments were necessary and should have been documented each time pain medication was administered. The facility's policies on pain management and medication administration required licensed nurses to complete pain assessments for residents identified as having pain, administer pain medication as ordered, and re-evaluate and document the resident's pain level within one hour after medication. The failure to follow these protocols resulted in inadequate monitoring and documentation of pain management for both residents.