Failure to Assess and Document Pain Management According to Orders
Penalty
Summary
A resident with multiple complex medical conditions, including chronic heart failure, end stage renal disease, diabetes mellitus, and depression, was admitted and later returned from the hospital with a new order for hydrocodone-acetaminophen to be administered every eight hours as needed for severe pain. The physician's order specified that nonpharmacological interventions should be attempted and that the medication was to be used for severe pain only. However, the facility failed to consistently assess and document the resident's pain, including the location and severity, at the time of medication administration. Pain medication was administered on several occasions for pain levels that were not classified as severe, and documentation was missing or incomplete regarding the pain's description and assessment during these times. Additionally, the resident's care plan did not address pain management, despite ongoing reports of pain and a new pain medication order. Progress notes lacked details about the pain for each administration of the as-needed medication, and there was no evidence of assessment for changes in the resident's pain condition. The facility's pain management policy required monitoring, evaluation, and care planning for residents experiencing pain, but these steps were not followed for this resident.