Failure to Document and Monitor Opioid Pain Management
Penalty
Summary
The deficiency involves the facility’s failure to provide and document safe, appropriate pain management for a resident following right knee replacement surgery. The resident was cognitively intact and had an admission MDS indicating occasional pain with an intensity of 5, with both scheduled and PRN pain medications ordered. The active orders included oxycodone 5 mg, with instructions to give 0.5 tablet for pain rated 4–6 and 1 tablet for pain rated 7–10. On two separate days, the resident reported significant right knee and lower leg pain, describing it as aching, throbbing, shooting, and constant, with self-reported pain scores ranging from 6/10 to 9/10. In both instances, the RN (V8) was notified of the resident’s pain complaints. On one day, the resident reported right knee and calf pain rated 6/10, and on another day, the resident reported severe right lower leg pain rated between 8 and 9/10, describing it as a new onset of constant, shooting pain and requesting a stronger pain medication (oxycodone) prior to therapy. The RN prepared and administered oxycodone 5 mg (1 tablet) in response to the resident’s complaint. The resident later reported that the oxycodone relieved some of the pain and allowed participation in therapy, although some pain remained. The facility’s electronic controlled substance record showed that the RN administered oxycodone 5 mg, 1 tablet, on both days in question. Despite the administration of oxycodone documented on the controlled substance record, the eMAR contained no entries showing that oxycodone was given on those days. Instead, the eMAR reflected pain levels of 2 and 0 on those dates, and there were no progress notes by the RN documenting the resident’s pain complaints, pain site, pain level, or any pain assessment. There was also no documentation of monitoring for effectiveness or adverse effects of the oxycodone that was administered, despite the resident’s care plan and facility policies requiring assessment, documentation of pain characteristics, monitoring of opioid effectiveness and side effects, and documentation of pain assessment results, medication, dose, route, and results. The DON confirmed that the oxycodone administrations were not documented in the eMAR and that there was no corresponding pain assessment or effectiveness monitoring in the medical record.
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