Failure to Assess Pain Level Prior to Administering PRN Analgesic
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pain management was provided consistent with professional standards of practice and the resident’s person-centered care plan. A cognitively intact female resident with arthritis and a pelvic fracture was admitted with orders for oxycodone 15 mg every six hours as needed for pain and scheduled methocarbamol 1000 mg four times daily. Her comprehensive care plan included monitoring and documenting pain and adverse reactions to analgesic therapy. On the day of the survey observation, the resident was lying in bed, groaning and grimacing, and verbally reported her pain as a 12 on a 1–10 scale, stating it hurt badly when she moved. At that time, an LVN entered the room with water and a pill cup, did not introduce herself, did not ask the resident to rate her pain, and then left the room after administering the medication. The LVN later confirmed she had given oxycodone for pain and admitted she did not assess the resident’s pain level, stating she “just did not” and was unaware the resident’s pain was at a level 12. She acknowledged she was supposed to ask the pain level to determine if the medication was effective. The DON stated that nurses were expected to assess residents’ pain levels to see if pain medicine was working. The facility’s pain management policy required asking the resident to rate pain intensity using a numerical, verbal, or visual scale preferred by the resident, which was not followed in this instance.
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