Failure to Assess Pain for Resident Receiving Scheduled Pain Medications
Penalty
Summary
Facility staff failed to assess the pain of a resident who was receiving scheduled pain medications, as required by the facility's pain management policy. The policy mandates that pain management must be provided in accordance with professional standards, the resident's care plan, and their goals and preferences, including regular reassessment for effectiveness and adverse effects. Despite this, there was no documentation of pain assessment before or after the administration of scheduled pain medications for the resident. The resident in question had a medical history including a left below-the-knee amputation, spinal stenosis, anxiety, and depression. On the day of observation, the resident was alert, appeared pale, had a damp hairline, and was breathing rapidly, and reported being in pain while waiting for her morning medication. The resident's medical record showed scheduled orders for hydrocodone, pregabalin, and tizanidine, but lacked any pain assessment documentation related to these medications. The DON confirmed that pain assessments were not performed as required.