Failure to Consistently Document Pain Assessments and Non-Pharmacological Interventions
Penalty
Summary
The facility failed to consistently monitor and document pain management interventions, including the use of non-pharmacological interventions (NPI), for four residents with significant medical conditions such as respiratory failure, stroke, quadriplegia, metabolic encephalopathy, anxiety, and depression. For these residents, the medication administration records (MAR) showed missing or incomplete documentation of pain assessments, pain locations, and the use of NPIs prior to administering as-needed pain medications such as acetaminophen, oxycodone, and tramadol. In several instances, pain was recorded using numerical scales, but the corresponding pain site or NPI attempts were not documented as required by facility policy and provider orders. Staff interviews confirmed that the expected practice was to offer and document NPIs before administering as-needed pain medications, but this was not consistently done. Specific examples included multiple occasions where residents received pain medications without any record of NPIs being offered or documented, and staff acknowledged these omissions during interviews. The lack of proper documentation and inconsistent monitoring of pain and NPIs did not meet the facility's expectations and requirements for safe and appropriate pain management.