Failure to Administer and Document Scheduled Pain Management as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to provide and document pain management as ordered for two cognitively intact residents with documented pain. One resident, admitted with conditions including a right knee contusion, muscle weakness, and need for assistance with personal care, had an MDS showing a BIMS score of 15 and an average pain intensity of 7/10 over the prior five days. This resident had a physician’s order for Hydrocodone-Acetaminophen 5-325 mg, one tablet by mouth every 8 hours for chronic pain, but the MAR for January showed missed scheduled doses on two occasions. In interview, the resident reported not receiving pain medication as scheduled and stated that when this occurred, she experienced pain for the rest of the day. The Activities Director recalled that this resident had filed a grievance a few months earlier about not receiving medications, but did not know the outcome. The second resident, admitted with diagnoses including generalized anxiety disorder, age-related osteoporosis, and unspecified abdominal pain, had an MDS showing a BIMS score of 13 and an average pain intensity of 7/10 over the prior five days. This resident had a physician’s order to monitor and record pain every shift on a 0–10 scale, but the MAR showed a missing pain assessment on one night shift and documented severe pain (10/10) and moderate pain (5/10) on other shifts. The resident also had multiple scheduled pain medication orders, including oxycodone 5 mg every 8 hours and Hydrocodone-Acetaminophen 5-325 mg and 7.5-325 mg via G-tube every 6 hours, with the MAR showing missed doses on several dates and unclear entries such as “NA” and “9 (see progress notes)” without corresponding progress note documentation. In interview, this resident reported sometimes not receiving scheduled pain medication, resulting in severe pain. The Regional Nurse Consultant acknowledged that both residents should have received medications as ordered and that any omitted doses should have been accompanied by appropriate documentation, consistent with the facility’s medication administration policy requiring administration per prescriber orders, timely administration within 60 minutes of scheduled time, and immediate documentation on the MAR.
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