Failure to Document Pain Assessments and Nonpharmacological Interventions Prior to Pain Medication Administration
Penalty
Summary
The facility failed to provide necessary care and services for pain management for two residents who required such services. For one resident, physician orders required the implementation and documentation of nonpharmacological interventions for pain, as well as a complete pain assessment prior to administering acetaminophen. However, medical record reviews showed that nonpharmacological interventions and their effectiveness were not consistently documented before administering the pain medication. Additionally, the required pain assessments, including details such as pain location, quality, characteristics, and alleviating or aggravating factors, were not documented in the progress notes prior to medication administration. For the second resident, physician orders specified the administration of hydrocodone-acetaminophen for moderate to severe pain, with the care plan requiring documentation of pain characteristics such as quality, severity, anatomical location, onset, duration, aggravating, and relieving factors. Review of the medication administration records revealed that, although pain levels were recorded, there was a lack of documentation regarding the location and characteristics of the pain at the time pain medication was given. Interviews with nursing staff and the DON confirmed that the expected practice was to assess and document pain characteristics and to implement and document nonpharmacological interventions prior to administering pain medication. The staff acknowledged that these steps were not consistently followed or documented for the two residents, as required by facility policy and care plans.