Failure to Document Comprehensive Pain Assessments and Non-Pharmacological Interventions
Penalty
Summary
The facility failed to provide safe and appropriate pain management for residents requiring such services. Specifically, staff did not document the reasons for administering as-needed (PRN) pain medications, nor did they record comprehensive pain assessments that included the intensity, location, and description of pain. Additionally, non-pharmacological interventions (NPI) were not implemented or documented prior to administering pain medications, as required by facility policy and physician orders. For two residents reviewed, one received acetaminophen on multiple occasions with only the pain intensity recorded, lacking documentation of pain location, description, and use of NPI. Another resident was administered oxycodone and acetaminophen regularly, but the records did not consistently include pain assessments or documentation of pain characteristics and NPI. The DON confirmed that pain management should include assessment of location, intensity, description, and effectiveness, as well as the use of NPI, and acknowledged the documentation deficiencies upon review.