Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide adequate pain management for a resident, resulting in a significant deficiency. The resident, who was admitted with a history of lumbar vertebra fracture, uterine cancer, and bone cancer, was not administered pain medication in a manner that effectively managed their pain. Despite having a comprehensive care plan that included administering medications as ordered and notifying the physician if interventions were unsuccessful, the facility did not adhere to these guidelines. The resident expressed severe pain, rated at 10 out of 10, and the family member had to call 911 to have the resident transported back to the hospital. The facility's policies on medication administration and pain management were not followed. The Medication Administration Record showed that the resident received excessive acetaminophen, exceeding the prescribed limit of 3000 milligrams in 24 hours, within just over 13 hours. Additionally, the facility failed to administer the appropriate dosage of oxycodone for the resident's reported pain level. The resident's pain was not reassessed within the 30-60 minute window as required by the facility's policy, and there was a lack of documentation for some medication administrations. Interviews with family members and staff revealed that the resident was in distress due to unmanaged pain and other unmet needs, such as soiled clothing and lack of food. The Director of Nursing acknowledged that Tylenol was administered for severe pain, but did not confirm if this was appropriate. The facility's failure to manage the resident's pain effectively and adhere to their own policies resulted in the resident being sent back to the hospital for proper care.
Plan Of Correction
Plan of Correction: Approved January 17, 2025 1. Resident #112 no longer resides in facility. Registered Nurse #4 no longer employed at facility. 2. All residents have the potential to be affected by the deficient practice. Nursing managers conducted a 90-day look back audit from 10/13/2024 - 1/13/2025 of all residents’ pain scales to determine other residents who have triggered for pain and received appropriate pain relief. 3. The Facility systemic changes: The policy titled Pain Management was reviewed by administration with no revisions necessary. The Facility educator will re-educate licensed staff on the policy titled “Pain Management.” Re-education will focus on provider notification with any resident reports of increased pain that is not being relieved with current interventions for further directive. 4. The Nurse Managers will conduct reviews of those residents who have triggered for pain to ensure appropriate intervention and provider notification. Pain medication reviews will be completed weekly x 4 weeks then monthly x 3 months. Results of reviews will be submitted at QAPI for review and determination of frequency reviews required. Responsible Party: Director of Nursing