Failure to Document Follow-Up Pain Assessment After PRN Analgesic Administration
Penalty
Summary
Facility staff failed to provide appropriate follow-up assessment for a resident who reported serious pain after receiving pain medication. Clinical record review showed that the resident had an existing order for Tylenol Extra Strength 500 mg to be administered in the morning for pain. On 12/30/25, the resident reported pain rated 8 out of 10 and was given the ordered Tylenol at approximately 9:00 AM. However, there was no documented evidence that nursing staff returned to reassess the resident’s pain level or evaluate the effectiveness of the medication after administration. Further review of the clinical record showed that later that same day, at 5:00 PM, the physician added a new order for Tylenol Extra Strength 500 mg, one tablet every 8 hours, for the diagnosis of pain. The resident received the first dose under this new order at 6:02 PM and had a documented pain level of 0 afterward. During an interview, the DON was shown the December 2025 MAR, including the documented pain level of 8 on 12/30/25 and the absence of a follow-up pain assessment. After reviewing the concern with the unit manager, the DON confirmed they could not find evidence that a nurse had followed up on the effectiveness of the morning pain medication dose.
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