Failure to Document Pain Assessments Before and After Narcotic Administration
Penalty
Summary
The facility failed to ensure that pain assessments were completed both prior to and after the administration of narcotic pain medication for two residents. For one resident with diagnoses including dementia, chronic kidney disease, malignant melanoma, anxiety disorder, and chronic lumbar degeneration, there were multiple instances where Oxycodone was administered without documentation of a pain assessment before or after the medication was given, as required by the physician's order and the EMAR. Specific dates and times were identified where this documentation was missing. Another resident, with diagnoses such as dysarthria following cerebral infarction, right shoulder stiffness, type II diabetes with neuropathy, and major depressive disorder, also received Oxycodone without the required pain assessments being documented before and after administration. Interviews with both residents and a family member indicated that the residents had not requested strong pain medication recently, and one preferred Tylenol for pain. The Executive Director confirmed that the LPN should have completed pain assessments as required.