Failure to Provide Consistent and Documented Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for multiple residents, as evidenced by inconsistent documentation and administration of pain medications, lack of adequate medication parameters, and insufficient assessment and monitoring of pain. For one resident, Dilaudid (Hydromorphone) was ordered as needed for pain, but records showed that the medication was removed from the controlled lock box on several occasions without corresponding documentation in the Medication Administration Record (MAR) or evidence that the resident's pain level and the effectiveness of the medication were monitored. The Director of Nursing confirmed that staff did not ensure the medication was administered as ordered. Another resident with a history of dementia, chronic pain, and a previous hip fracture had orders for both Acetaminophen and Tramadol for pain, but the orders lacked clear parameters for when each medication should be used. Documentation showed that pain medications were administered without recording the location or source of pain, and there was no evidence that non-pharmacological interventions were attempted prior to giving narcotic pain medication. Pain assessments before and after medication administration were inconsistently documented, and the effectiveness of interventions was not always evaluated as required. A third resident experienced a right humeral fracture and was described as being in excruciating pain, but the MAR did not show that scheduled or as-needed pain medication was administered during the period of severe pain, except for a single dose. There was no documentation of further pain interventions prior to the resident's transfer to the emergency room, despite orders allowing for additional pain medication. These findings were confirmed through record review and interviews with facility leadership.