Failure to Assess and Monitor Pain Management
Penalty
Summary
The facility failed to assess a resident's pain prior to administering scheduled pain medication and did not monitor the effectiveness of the pain management provided. Record review showed that the resident had a physician's order for scheduled Tramadol HCL 50 mg three times daily for pain, and the resident's Minimum Data Set (MDS) assessment indicated frequent pain rated as 8 out of 10, which limited daily activities. However, the Medication Administration Record for the resident did not include any documentation of pain level assessments at the time of medication administration. Additionally, there was no physician's order in place to assess the resident's pain or to monitor the effectiveness of the scheduled pain medication. The resident's care plan included an intervention to evaluate the effectiveness of pain-relieving interventions, but this was not implemented as required. An interview with a registered nurse confirmed that there was no order or process in place for pain assessments or monitoring the effectiveness of the scheduled pain medication for this resident.