Inadequate Assessment and Indication for Opioid Pain Medication
Penalty
Summary
Surveyors identified a deficiency related to unnecessary medications when the facility failed to ensure appropriate assessment and indications for opioid pain medication use for one resident with other acute osteomyelitis of the left ankle and foot. The facility’s Pain Management policy dated 12/2/25 required that pain be assessed every shift, recorded on the eMAR, with the pain scale used and the type of pain documented, and that pain management be consistent with professional standards of practice and the resident’s care plan, goals, and preferences. For this resident, there was a physician order for acetaminophen 325 mg, two tablets by mouth every 8 hours as needed for mild acute pain, not to exceed 3000 mg/day. The record showed acetaminophen was administered once on March 8 at 0837 for a pain level of 4, with no further documented administration of acetaminophen from March 9 through March 16. The same resident also had a physician order for Percocet 5-325 mg (oxycodone with acetaminophen), one tablet by mouth every 4 hours as needed for moderate to severe acute pain related to the osteomyelitis diagnosis. However, the medical record documented that Percocet was administered on three occasions—March 13 at 0707, March 15 at 0621, and March 16 at 0625—each time for a documented pain level of 3, which is below the ordered indication of moderate to severe pain. During an interview on March 17 at 12:58 PM, the DON stated that physicians had moved away from using the pain intensity number scale because some residents might report a pain level of 3 when it is really a 6 or 7, indicating a discrepancy between the documented pain scores and the ordered criteria for opioid use.
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