Inadequate Pain Management for Residents
Penalty
Summary
The facility failed to provide adequate pain management for two residents, leading to deficiencies in care. Resident #30, who had diagnoses including osteoarthritis and vertebral artery stenosis, frequently experienced pain but did not receive proper pre and post pain evaluations when as-needed pain medication was administered. Observations noted the resident displaying signs of pain such as facial grimacing and moaning, yet the pain flow sheets were left blank, lacking documentation of the resident's pain levels and the effectiveness of the administered medication. Interviews with staff revealed a reliance on the resident to verbalize pain, despite their severely impaired cognition, and a lack of documentation of pain assessments. Resident #53, diagnosed with osteoarthritis and muscle weakness, experienced pain during transfers, particularly when using the sit-to-stand lift. Despite the resident's verbal complaints of pain during these transfers, there was no documented evidence of pre or post pain evaluations when as-needed Tylenol was administered. Observations showed the resident expressing pain during the transfer process, yet staff did not adequately address these complaints. Interviews with staff indicated an awareness of the resident's pain during transfers, but there was no follow-up with therapy or adjustments to the transfer process to alleviate the resident's discomfort. The facility's policy on pain assessment and management was not adhered to, as evidenced by the lack of documentation and follow-up on residents' pain levels and the effectiveness of pain interventions. The Director of Nursing acknowledged the expectation for nursing staff to document pre and post pain evaluations, highlighting a gap in practice that contributed to the deficiency. The failure to properly assess and document pain management interventions resulted in inadequate care for the residents involved.
Plan Of Correction
Plan of Correction: Approved March 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F697- Pain Management: Crouse Community Center will ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive centered care plan, and the resident’s goals and preferences. Corrective action: For resident #30, a new pain assessment and a therapy referral were completed. Medications were adjusted and is due for a review with provider. Care plan interventions updated. Resident #53 was transitioned to comfort care upon review of her MOLST with the family members and medication changes were made; she expired on [DATE]. Other residents: All licensed staff will be re-educated with the pain management policy which includes emphasis on pre and post pain evaluation and pain management documentation to ensure that pain management is appropriate and effective for all residents. All non-licensed staff will be re-educated on change in condition communication, pain identification, and reporting. Systemic changes: Pain Assessment and Management policy was updated and training will include accurate pain flow assessment record documentation and staff communication to ensure referrals to appropriate sources (i.e. therapy, psychosocial, medical, outside agencies referrals) were made. Monitoring: Audits will be conducted by the Director of Nursing monthly on pain flow sheet completion, and resident specific comprehensive care plan interventions. The audit will be reported to QAPI monthly with 100% compliant threshold expected. Responsible Party: Director of Nursing