Failure to Follow Pain Medication Orders and Pain Assessment Protocols
Penalty
Summary
A deficiency occurred when a resident with multiple pain-related diagnoses, including lumbar spondylosis, rheumatoid arthritis, lumbosacral radiculopathy, and fibromyalgia, did not receive pain management services consistent with professional standards of practice. The resident had physician orders for oxycodone to be administered as needed for moderate to severe pain (pain level 4-10) and Tylenol for mild pain (pain level 1-3). The resident's care plan directed staff to administer medications as ordered to address pain and discomfort. Record review revealed that on one occasion, both oxycodone and Tylenol were administered simultaneously for pain levels of 7/10 and 4/10, respectively, which did not align with the prescribed parameters. Additionally, oxycodone was given at another time when the resident's pain level was documented as 0/10, indicating no pain. The DON confirmed these discrepancies and acknowledged that the expectation was to follow the pain scale as ordered. The facility's policy required staff to implement the medication regimen as ordered, which was not followed in these instances.