Failure to Timely Assess and Address Ineffective Pain Management
Penalty
Summary
A deficiency was identified when a resident with an order for PRN traMADol for pain was administered the medication for a reported pain level of 7 out of 10. Documentation showed that the medication was not effective in relieving the resident's pain. However, there was no evidence in the Medication Administration Record (MAR) or Treatment Administration Record (TAR) that additional interventions were implemented or that the effectiveness of the pain medication was reassessed within the professional standard of one hour after administration. Interviews with nursing staff revealed that while non-pharmacological interventions such as ice packs might be offered, these were not consistently documented unless there was a physician's order. The Director of Nursing acknowledged that, based on available documentation, the reassessment of the pain medication's effectiveness was completed late, and additional interventions were not offered until several hours after the initial administration.