Failure to Document Pain Medication Effectiveness and Respond to Low Oxygen Saturation
Penalty
Summary
Facility staff failed to ensure that pain management services met professional standards for a resident receiving Methadone 10 mg PO BID and Oxycodone 10 mg PO q8h PRN. Review of the MAR showed that on 02/06 at 7:33 a.m., an LPN administered 10 mg of Oxycodone when the resident’s pain score was documented as 6, but there was no follow-up documentation in the EHR to verify whether the pain medication was effective. Interviews with an LPN and the DON confirmed that facility practice is to document pain scores before administration and a follow-up pain score 15–60 minutes after administration, and to contact the provider if the PRN medication is not effective. Further EHR review showed that a different LPN, who had worked the prior shift and had not administered the medication, documented the follow-up pain score for this dose, and the DON could not explain why this occurred. The facility also failed to meet professional standards in responding to a change in condition involving the same resident’s oxygen saturation. Review of the resident’s change in condition documentation and a CRISP report showed that while the resident was in distress, their oxygen saturation decreased to 86%–87%, but oxygen was not administered. The DON stated that during significant changes in condition, an in-house NP or on-call provider is notified for recommendations, and acknowledged that although the nurse contacted the provider, the nurse did not recognize the drop in oxygen saturation and that administering oxygen is a nursing judgment that was not exercised in this case.
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