Failure to Monitor Effectiveness of Scheduled Opioid Pain Medication
Penalty
Summary
The facility failed to consistently evaluate the effectiveness of regularly scheduled opioid pain medication for a resident with chronic pain conditions, including fibromyalgia and polyarthritis. The resident had a physician's order for Tramadol 50 mg twice daily for pain management, and the care plan required evaluation of the medication's effectiveness, review of compliance, symptom alleviation, dosing schedules, resident satisfaction, and impact on functional ability and cognition. However, review of the medication administration record, treatment administration record, and progress notes revealed no documentation of pain scale assessments or evaluation of the medication's effectiveness during the specified period. Interviews with nursing staff confirmed that there was no pain scale or documentation of pain assessment or medication effectiveness for this resident, despite facility policy requiring such monitoring for residents identified with pain. The facility's pain management policy specified the use of a consistent pain scale, regular re-evaluation, and documentation of pain monitoring, but these procedures were not followed for the resident receiving scheduled Tramadol.