Failure to Reassess Pain After Medication Administration
Penalty
Summary
A deficiency occurred when a resident with chronic back pain, generalized osteoarthritis, and muscle weakness did not receive appropriate pain management. The resident was prescribed tramadol 50 mg every 12 hours as needed for moderate to severe pain, with care plan interventions specifying that medication should be administered as ordered and its effectiveness monitored. On the day in question, the resident received tramadol for severe pain, but there was no follow-up assessment of pain level after administration, as required by both the care plan and facility policy. The resident later reported ongoing moderate pain and stated that the nurse did not return to reassess his pain after giving the medication. The nurse confirmed that she did not reassess the resident's pain level after administering tramadol, acknowledging that she should have done so within 30 minutes to an hour to ensure the medication's effectiveness. The DON also stated the importance of assessing pain before and after medication administration to evaluate effectiveness and monitor for side effects. The facility's policy required pain management interventions to be consistent with the resident's goals and specifically documented, which was not followed in this instance.