F0842

D

Inaccurate Pain Management Documentation and Staff Credential Recording

Rexburg, Idaho Survey Completed on 01-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain accurate medical records for residents, specifically related to pain management documentation. For one resident with a right above-knee amputation and diabetes, the November 2025 MAR showed that Percocet 10-325 mg was administered on three occasions and documented as given by CNA #4. Review of the active employee list showed that this staff member was listed as a registered nurse with specific hire, termination, and rehire dates. The DON stated that CNA #4 was currently working as a registered nurse and that the facility had been unable to change her credentials in the electronic medical record system, resulting in inaccurate staff credential information on the MAR.

For another resident with an above-knee amputation, multiple sclerosis, and chronic pain syndrome, physician orders dated 10/8/25 directed application of a Fentanyl 75 mcg/hr patch every three days, and an order dated 10/3/25 required documentation of the patch site every shift. The December 2025 MAR documented the dates, times, and shoulder locations where the Fentanyl patch was applied, as well as Q-shift documentation of the patch site. On review, a discrepancy was identified between the documented administration/site entries and the Q-shift site observations for the Fentanyl patch. The DON stated that nurses should have been documenting the correct site of the Fentanyl patch on the MAR and had not, resulting in inconsistent and inaccurate documentation for this resident’s pain management treatment.