Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for two residents, resulting in deficiencies related to the administration and documentation of pain medication. One resident reported experiencing significant pain, rating it as an eight out of ten, and stated she had been requesting pain medication without receiving it. The nurse on duty initially withheld the medication due to a misunderstanding of the dosing interval, only contacting the physician to adjust the order after the resident's continued complaints. Documentation review revealed discrepancies between the controlled substance log and the Medication Administration Record (MAR), with several instances where pain medication was signed out but not documented as administered on the MAR, and no evaluation of the medication's effectiveness was recorded as required by facility policy. Another resident, admitted for therapy following an unrepaired hip fracture, also reported ongoing pain and concern about participating in therapy due to inadequate pain control. Review of her medical records showed multiple changes in pain medication orders, but again, there were instances where pain medication was signed out on the controlled substance log without corresponding documentation on the MAR or evaluation of effectiveness. The DON was unable to provide documentation for a reported refusal of alternative pain medication and made comments regarding the resident's pain tolerance without supporting evidence. Both cases demonstrate failures to follow professional standards of practice, the comprehensive care plan, and the residents' choices regarding pain management. The lack of proper documentation and timely administration of pain medication, as well as failure to assess and record the effectiveness of pain interventions, contributed to the deficiency identified during the survey.