Failure to Assess and Document Pain Management for Resident Receiving Scheduled Pain Medications
Penalty
Summary
Facility staff failed to assess the pain of a resident who was receiving scheduled pain medications, as required by the facility's pain management policy. The policy mandates that pain management must be provided in accordance with professional standards, the resident's care plan, and their goals and preferences, including regular reassessment for effectiveness and adverse effects. However, review of the medical record for a resident with a history of left below the knee amputation, spinal stenosis, anxiety, and depression revealed no documentation of pain assessment before or after administration of scheduled pain medications, which included hydrocodone, pregabalin, and tizanidine. During an interview, the resident reported being in pain and noted delays in receiving morning medication, particularly when agency nurses were on duty. The Director of Nursing confirmed that pain assessments were not performed or documented prior to or after medication administration, acknowledging that the pain scale was missing from the record. This lack of assessment and documentation represents a failure to follow the facility's own pain management policy and to ensure appropriate pain management for the resident.