Failure to Reassess Pain Management for a Resident
Penalty
Summary
The facility failed to reassess a resident's pain status and the repeated daily use of opioid pain medication prescribed on an as-needed (PRN) basis, which led to the deficiency. Resident 28, who was admitted with diagnoses including dementia and polyneuropathy, frequently experienced severe pain and was receiving both daily and PRN pain medications. Despite the significant increase in PRN opioid use, the facility did not conduct additional pain assessments to justify this increase or modify the pain management plan accordingly. The facility's policy required comprehensive pain assessments at specific intervals, but no such assessments were documented after October 2024. The Director of Nursing confirmed that no comprehensive pain reassessment had been conducted to determine the effectiveness or appropriateness of the resident's pain management regimen. The lack of reassessment and adjustment of the pain management plan did not align with professional standards of practice, clinical guidelines, or the facility's own policy. This resulted in the potential for unmanaged pain, unnecessary opioid exposure, or adverse medication effects, failing to ensure that the resident's pain management was individualized, effective, and consistent with their needs, goals, and preferences.
Plan Of Correction
Resident 28 was discharged from the facility. A 30 day look back audit of current resident's PRN opioid use will be completed to identify significant changes in pain. Any discrepancies found will have a comprehensive pain assessment completed to determine the effectiveness of the resident's pain management regime. RN licensed nurses will be educated regarding how to accurately complete comprehensive pain assessments. Licensed nurses will be educated regarding pain management policy. Random monthly audits will be completed by the DON/designee of PRN opioid use x 3 months. Random audits will be reviewed at monthly QAPI x 3 months.