Failure to Document and Implement Effective Pain Management Interventions
Penalty
Summary
A deficiency was identified when a resident with a history of post-right hip surgery for a fracture did not receive effective pain management as required. The resident had provider orders for non-pharmacological interventions (NPIs) to be attempted and documented prior to administering PRN opioid pain medication for pain levels between 4 and 10. Review of the medical record and medication administration records (MAR) revealed that while the resident received pain medication on multiple occasions for reported pain levels within the ordered range, there was no documentation of pain assessments prior to medication administration, including the specific location and type of pain, nor any record of which NPIs were attempted before giving the medication. Additionally, after administration of pain medication, the resident continued to experience pain at lower levels on several dates, but the records did not indicate what actions, if any, staff took to further manage the resident's ongoing pain. During an interview, the DON confirmed that her expectation was for staff to attempt NPIs before administering pain medication and to continue managing the resident's pain if it persisted, but the documentation did not reflect these practices.