Failure to Assess and Manage Pain According to Physician Orders
Penalty
Summary
The facility failed to provide necessary care and services for a resident requiring pain management by not conducting a complete pain assessment prior to administering pain medication and by not following the physician's orders for pain management. According to the facility's pain management policy, staff are required to reassess pain at regular intervals and document pain characteristics such as frequency, duration, intensity, location, and factors that aggravate or alleviate the pain. However, medical record review revealed that for multiple instances when the resident reported moderate to severe pain (pain levels 5-8), acetaminophen was administered instead of the prescribed hydrocodone-acetaminophen for pain levels above 3, and there was no documentation of pain characteristics or assessment prior to medication administration. Interviews with LVNs and review of the medical record confirmed the absence of required documentation regarding the resident's pain, including its location, characteristics, and related factors. Staff were unable to locate this documentation and acknowledged that the correct medication was not administered according to the physician's orders for higher pain levels. The DON was informed of these findings and acknowledged the deficiencies in pain assessment and medication administration for the resident.