Failure to Provide Physician-Ordered Pain Management and Documentation
Penalty
Summary
The facility failed to provide appropriate pain management services as ordered by physicians for two residents. In the first case, a resident with an order for PRN oxycodone for severe pain reported experiencing severe pain and waiting several hours for medication, only to be told by nursing staff that the medication was unavailable. Review of medication records and the narcotic sign-out sheet confirmed that the last dose had been administered earlier that morning and that no further medication was available in the facility at the time of the resident's request. In the second case, a resident with chronic pain had physician orders requiring non-pharmacological interventions (NPIs) to be attempted prior to administering PRN pain medication. Review of the medical record and medication administration records revealed that there was no documentation of pain assessments or attempts at NPIs before administering the PRN pain medication on several occasions. The lack of documentation included missing information on pain location, type, and whether NPIs were attempted prior to medication administration.