Deficient Pain Management and Documentation for Two Residents
Penalty
Summary
Two deficiencies were identified regarding pain management for two residents. For the first resident, who had diagnoses including generalized arthritis, syncope, and chest pain, the facility failed to administer acetaminophen as prescribed. The physician's order specified acetaminophen for mild pain (pain scale 1-3), but the medication was administered when the resident reported a pain level of four. The Assistant Director of Nursing (ADON) confirmed that the medication should not have been given for a pain level outside the prescribed range and that the physician should have been contacted for an alternative order appropriate for the resident's pain level. For the second resident, who had diagnoses including Parkinson's disease, encephalopathy, and low back pain, the facility failed to ensure that licensed nurses attempted and documented nonpharmacological interventions before administering as-needed hydrocodone-acetaminophen for severe pain. The resident's care plan included non-medication interventions such as repositioning and distraction, but the Medication Administration Record (MAR) showed that these interventions were not documented as attempted prior to administering the narcotic medication on multiple occasions. The ADON acknowledged that nonpharmacological interventions should have been implemented and documented first, in accordance with facility policy. Both deficiencies were found to be inconsistent with the facility's policies on pain assessment and medication administration, which require medications to be given as prescribed and nonpharmacological interventions to be considered prior to administering narcotic pain medications.