Failure to Assess and Document Pain Characteristics Prior to Medication Administration
Penalty
Summary
A deficiency was identified when a nurse failed to assess and document the location and characteristics of a resident's pain prior to administering pain medication. The resident, who had a history of joint replacement surgery, intracerebral hemorrhage, and right knee osteoarthritis, reported pain in his mouth due to repeated accidental biting and in his right knee related to arthritis and recent surgery. The resident was cognitively intact and required some assistance with activities of daily living. On a specific occasion, the resident was administered oxycodone for a reported pain level of 6/10, but the nurse did not assess or document the pain's location or quality before giving the medication. The nurse acknowledged that she should have performed and documented a full pain assessment, including site and type of pain, but did not do so. The facility's policy required such assessments to ensure effective pain management, but this was not followed in this instance.