Failure to Ensure Proper Pain Management and Documentation
Penalty
Summary
The facility failed to ensure proper monitoring and documentation of pain management for two residents. For one resident with diagnoses including myositis and dyspnea, a physician ordered hydrocodone-acetaminophen to be administered as needed for pain. On a specific date and time, the Medication Administration Record (MAR) showed that a Medication Aide Certified (MAC) documented a pain level of 5 and administered the medication, but there was no licensed nurse (LN) assessment of pain documented prior to administration, as required. The Director of Nursing (DON) confirmed that a licensed nurse should have documented the pain assessment before the medication was given, but this did not occur. For another resident with chronic respiratory failure, diabetes, and chronic pain, the care plan required pain assessments every shift and administration of analgesics as ordered. Physician orders specified that oxycodone should be given only for moderate to severe pain (pain rating of 4 or higher). However, the MAR showed that oxycodone was administered on multiple occasions when the resident's pain assessment was documented as zero. The DON confirmed that the medication should only have been administered for pain ratings of 4 or higher and that documentation was insufficient when administering as-needed pain medications.