Failure to Follow Pain Management Protocols and Documentation Requirements
Penalty
Summary
The facility failed to provide safe and appropriate pain management for three residents by not following physician orders for pain assessment, documentation, and medication administration. For two residents, physician orders required pain to be monitored and documented every shift, but medical record reviews showed that pain assessments were not consistently performed or recorded as ordered. In several instances, pain levels were only documented sporadically, and there were gaps in the monitoring records for entire shifts. Additionally, pain medications were not administered according to the prescribed pain level parameters. One resident received acetaminophen for a pain level below the ordered threshold, and another resident was given hydrocodone-acetaminophen for pain levels that did not meet the criteria for severe pain as specified by the physician's order. These deviations from the prescribed medication protocols were verified by facility staff during interviews and record reviews. The facility also failed to ensure that non-pharmacological interventions were attempted and documented prior to administering pain medications, as required by both physician orders and facility policy. For one resident, there was no documentation of non-pharmacological pain interventions before medication administration, and staff confirmed that these interventions should have been implemented and recorded. The lack of adherence to pain management protocols and documentation requirements was acknowledged by the ADON, LVN, and other facility leadership during interviews.