Failure in Pain Management Protocols
Penalty
Summary
The facility failed to provide effective pain management for a resident, as evidenced by the administration of pain medication without attempting non-pharmacological interventions first. The facility's policy on pain management, which was reviewed, requires the development and implementation of both non-pharmacological and pharmacological interventions tailored to the resident's needs. However, the facility did not adhere to this policy for one resident, who was administered pain medication without documented attempts of non-pharmacological interventions. The resident in question, admitted with multiple diagnoses including cerebral palsy, dysphagia, and contractures, had a comprehensive person-centered care plan that included goals for adequate pain relief. Despite this, the facility's records showed repeated instances where pain medication was administered without prior non-pharmacological interventions. This occurred multiple times over a period from January to February 2025, with pain levels documented as moderate to severe. Interviews with the Director of Nursing confirmed the lack of adherence to physician's orders and the absence of documented non-pharmacological interventions. The facility's failure to follow its own pain management policy and physician's orders resulted in a deficiency in providing appropriate care for the resident's pain management needs.
Plan Of Correction
Preparation and/or execution of this plan of correction in general, or this corrective action does not constitute an admission of agreement by this facility of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction and specific corrective actions are prepared and/or executed in compliance with State and Federal laws. Identify and care plan nonpharmacological interventions for the resident's current pain management strategy. Using an interdisciplinary approach, review residents who currently receive pain medications, scheduled or as needed. Implement nonpharmacological interventions, relaxation techniques, back rub, lights, toilet, food/drink, and reposition. Education for all nursing staff to improve the quality of pain management to ensure resident outcomes enhance safety, physical and emotional functioning, and quality of life. In the development of a resident's individualized plan of care for pain management, consider a multidisciplinary approach, therapeutic, nonpharmacological interventions, and medication management. Educate clinical staff on the use of strategies for the management of pain including developing and implementing both nonpharmacological and pharmacological interventions to pain management. The Interdisciplinary Care Team will conduct five random audits weekly to review the clinical practice of pain management, including the application of nonpharmacological interventions and assessment of decrease in pain intensity, improved functional mobility, and reduction in pain-related distress. The audits will be reviewed weekly in the Risk Meeting and present monthly x3 in QAPI.