Failure in Pain Management for Resident
Penalty
Summary
Nottingham Village was found to be non-compliant with the pain management requirements as outlined in 42 CFR Part 483, Subpart B. The facility failed to provide adequate pain management for a resident who had been admitted with severe injuries, including a displaced bimalleolar fracture and a displaced osteochondral fracture. On January 19, 2025, the resident was found on the floor, complaining of severe pain, which was assessed as a seven out of ten. Despite the resident's complaints and nonverbal signs of pain, the facility did not implement the pain management program as per their policy, which required pain assessment every shift and updating the physician if pain was not managed effectively. The facility's documentation revealed that the resident was not administered any as-needed Tylenol on the day of the incident, despite having an order for it. Furthermore, there were no further assessments of the resident's pain after the initial assessment on the first shift. Interviews with the resident and the Director of Nursing confirmed these findings, indicating a failure to adhere to the facility's pain management policy and to address the resident's severe pain adequately.
Plan Of Correction
1. Resident # 1's Pain has been re-assessed and is reporting her pain is being managed. 2. DON / Designee will audit the month of February MAR's to identify residents reporting over 7 pain. These residents will be assessed along with input from their PCP to determine if a new pain management regimen is necessary. 3. DON will conduct education with licensed nurses on the facility's pain management policy and include pain management focus when assessing residents post injury or accident. 4. DON / designee will audit random MAR's to determine if residents reporting over 7 pain are being managed properly; weekly x 4 weeks. DON / designee will audit IR's with reported injuries to validate pain has been assessed and managed properly; weekly x 4 weeks. Results of these audits will be reported to the QAPI team. 5. Date of compliance 3/13.