Failure to Administer PRN Pain Medications According to Orders and Pain Scale
Penalty
Summary
The facility failed to ensure that pain medications were administered according to physician orders and the facility’s own pain management policy for one resident. The facility’s policy on administering pain medications described the use of standardized numeric pain assessment tools and defined pain levels as mild, moderate, and severe, but the written policy did not specify which numeric scores corresponded to each level. In an interview, the DON clarified that the facility’s pain scale categorized scores of 1–3 as mild pain, 4–6 as moderate pain, and 7–10 as severe pain. Review of the resident’s clinical record showed diagnoses including back pain and physician orders for PRN Morphine Sulfate 15 mg every 6 hours as needed for severe pain and Acetaminophen 325 mg, two tablets every 6 hours as needed for mild pain, with no physician order addressing moderate pain. Medication administration records for January 2026 showed multiple instances where the resident’s documented pain score did not match the ordered indication for the administered medication. On several dates, the resident had pain scores of 4 or 5, which the facility defined as moderate pain, yet was given Morphine Sulfate ordered only for severe pain. On other dates, Morphine Sulfate was administered when the resident’s pain score was documented as 0, indicating no pain. There was also an instance where Acetaminophen for mild pain was given when the pain scale for that shift was documented as 0. In interviews, the DON and the administrator confirmed that Morphine was administered for pain scores less than severe and acknowledged that there was no pain management order in place for moderate pain.
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