Failure to Timely Reassess Pain After Medication Administration
Penalty
Summary
A deficiency occurred when a resident with chronic pain syndrome, a stage IV pressure ulcer, and on hospice care did not receive timely reassessment of pain following administration of pain medication. The resident's care plan required pain to be managed with both scheduled and PRN medications, and the facility's policy specified that pain intensity should be reassessed one hour after administration of pain medication. However, after the resident was given morphine for pain, the licensed nurse did not perform the required follow-up pain assessment within the one-hour timeframe. Instead, the nurse assessed the resident's pain nearly three hours after medication administration, at which time the resident continued to report pain, describing a sensation of having a ball inside her abdomen and rating her pain as a five while visibly grimacing and holding her abdomen. The nurse documented the follow-up assessment as "effective" despite the resident's ongoing pain. The DON confirmed that the facility's policy was not followed, as the reassessment should have occurred one hour after medication administration.