Failure to Document Pain Status During Missed Scheduled Pain Medication
Penalty
Summary
The facility failed to consistently document the pain status of a resident who was prescribed routine opioid pain medication for pain and discomfort related to a left ankle fracture. The resident, who had severe dementia and was receiving hospice services, did not receive his physician-ordered Norco for a period of five days, as indicated by the Medication Administration Record (MAR). During this time, the MAR entry for pain assessment was blocked out, preventing staff from entering pain assessments as required by the medication order. The resident did receive two doses of as-needed morphine sulfate during this period, with documentation showing a pain level of 4 out of 10 and that the medication was effective. However, no other documentation regarding the resident's pain status was found in the nursing progress notes for the days when the scheduled pain medication was not administered. Interviews with facility leadership, including the Executive Director, DON, and Assistant DON, revealed that they were unaware of any issues related to missed scheduled pain medications. The facility's pain management policy requires a systemic approach to pain recognition, assessment, treatment, and monitoring, including the use of an appropriate pain assessment tool for residents with cognitive impairment. Despite this policy, the lack of consistent pain assessment documentation during the period when the resident was without scheduled pain medication constituted a failure to provide safe and appropriate pain management services.