Incomplete Pain Assessment and Documentation
Penalty
Summary
A deficiency occurred when the facility failed to conduct a complete pain assessment for a resident with a history of urinary tract infection (UTI) and acute pain. The resident, who had recently had a urinary catheter removed, reported ongoing burning sensation during urination and rated her pain as 6 or 7 on a scale of 1-10. Although Tylenol was administered as ordered for severe pain, documentation in the progress notes and condition monitoring failed to include the location of the pain, despite the resident indicating discomfort in the bladder area. The care plan required monitoring and documenting the probable cause of each pain episode, but this was not fully carried out. Interviews with nursing staff and review of facility policy confirmed that the expected process was to document the location of pain when administering PRN pain medications. However, both the progress notes and condition monitoring records lacked this information for the resident on the relevant dates. The Director of Nursing also stated that staff were expected to assess and document the location of pain prior to medication administration, but this was not done in this case, resulting in incomplete pain assessment and documentation.