To comply with pain management regulations, there must be three elements that align: Complete pain medication orders with all required components, a valid pain assessment indicating the level of discomfort being experienced, and the administration of the correct medication and dosage based on the order and assessment. Our consultant teams often observe pain medication administration practices that are non-compliant with these requirements.
For example, pain medication orders include all required elements, including clear guidance on the level of pain. However, the assessed level of pain and the administration of pain medication do not match. Specifically, the order may read: “Acetaminophen 325mg, give two tablets every 4 hours PRN mild pain.” The pain assessment is documented as a pain level of 4; however, there is no policy indicating that a pain level of 4 is mild.
Additionally, we have noticed the use of pain assessment tools for patients with dementia or cognitive impairment without complete documentation of the associated pain level. Sometimes these patients are consistently medicated with more potent pain medications, which could question the accuracy of the assessment and whether the medication is being used as a chemical restraint. This practice is dangerous both from a regulatory compliance perspective and from a patient safety perspective due to the risk of over sedation.
Furthermore, we’ve noticed the use of tools, such as the Checklist of Nonverbal Pain Indicators (CNPI), that do not indicate a specific pain level in the assessed score. There is no organizational policy that guides the use of the tool to align the administration of pain medication with the prescribed pain level. Documentation by staff of PRN pain medication administration is inconsistent (Some administer mild pain medication for a CNPI score of 6, where some administer medication ordered for moderate pain).
Organizational leaders must ensure that Provider PRN pain medication orders, pain assessment tools, and administration practices are aligned with safe practice. Monitoring for inconsistencies and opportunities is critical. There are often opportunities beyond tracking for compliance with reassessment documentation after PRN pain medication administration.
Please contact us for questions or more information at 704-573-4535 or info@courtemanche-assocs.com.
Courtemanche & Associates specializes in Healthcare Accreditation and Regulatory Compliance Consulting Services. With over 30 years of being in business and 100+ years of healthcare experience amongst our consulting team, we are ready to assist with your accreditation and regulatory compliance needs.
