Failure to Consistently Document Pain Assessments and Medication Administration
Penalty
Summary
Surveyors identified that the facility failed to ensure consistent pain management and documentation for two of three residents reviewed for pain medication. Both residents had physician orders for as-needed oxycodone, with specific instructions to assess and document pain levels prior to and after administration. However, review of narcotic control sheets and medication administration records over several months revealed numerous instances where pain assessments were not documented as required, and administration of pain medication was not consistently recorded. For one resident with a history of bipolar disorder and multiple fractures, narcotic control sheets showed oxycodone was signed out frequently, but pain assessments and documentation in the medication administration record were missing for a significant number of administrations. The resident reported not receiving pain medication as needed, particularly during overnight shifts, and stated that their concerns were not addressed. Interviews with nursing staff confirmed that pain assessments were not always performed or documented, and that the narcotic book was sometimes used to track administration times instead of the medication administration record. Another resident with a femur fracture, pain, and a hip wound also had incomplete documentation of pain assessments and medication administration. Staff interviews revealed that documentation was often incomplete, leading to missed pain assessments before and after medication administration. The DON acknowledged that pain assessments would only be triggered in the medication administration record if the medication was documented as given, and confirmed that there was no consistent documentation of pain assessments for these residents.