Failure to Assess and Document Tolerable Pain Level and Follow Pain Medication Orders
Penalty
Summary
The facility failed to determine and document a resident's tolerable level of pain and did not administer pain medication according to the physician's order for one resident. The resident, who had a history of chronic pain syndrome and recent surgery, reported experiencing severe pain that was not adequately managed. The resident stated that the facility was not providing the same amount of pain medication as previously used at home and described an incident where a nurse declined to administer the usual dose of pain medication due to low blood pressure, while still administering medication to lower blood pressure. The resident rated their pain as a ten on a 0-10 scale, which prevented mobility. Review of the resident's clinical records showed that the physician's orders specified different dosages of pain medication based on the resident's reported pain level. Despite orders for two tablets of Oxycodone for pain rated 7-10, the Medication Administration Record documented that only one tablet was administered on multiple occasions when the resident reported pain levels of seven or higher. There was no documentation that the physician was contacted regarding the resident's low blood pressure or to obtain approval for altering the pain medication dosage. Additionally, the clinical record lacked documentation of an assessment or determination of the resident's tolerable pain level. Interviews with nursing staff and the DON confirmed that pain assessments were conducted using a 0-10 scale and that the resident was able to communicate their pain level. The DON acknowledged that the resident's tolerable pain level should be determined and documented, and that the physician's orders for pain medication were not followed as written. The facility's policy and procedures required collaboration with the resident and physician to develop and document individualized pain management plans, including the resident's tolerable pain level, but this was not reflected in the resident's record.