Failure to Document and Follow Pain Management Protocols
Penalty
Summary
The facility failed to ensure that Resident R102 received treatment and care in accordance with professional standards of practice. Resident R102, who was admitted with diagnoses including spastic quadriplegic cerebral palsy, major depressive and anxiety disorder, and dysphagia, was completely dependent on staff for all activities of daily living. The resident's care plan required regular pain assessments and documentation of non-pharmacological interventions, as well as medication administration and reassessment if necessary. On December 18, 2024, the resident was documented to be experiencing severe pain, rated 9/10, by an LPN during the day shift. However, there was no evidence that non-pharmacological interventions were attempted, nor was there documentation of medication administration or reassessment for effectiveness. Additionally, the resident was noted to be verbally crying out, but the clinical record lacked the required additional documentation as instructed by the physician. This failure to document and follow physician orders led to the deficiency.
Plan Of Correction
1. Resident R-102's pain is being controlled as per physicians' orders. 2. All residents who exhibit pain will be assessed to ensure that treatment and care in accordance with professional standards of practice occur. 3. Nurse Educator/Designee will re-educate the professional nursing staff on the policy, "Change in Resident Condition." 4. The DON/Designee will conduct weekly random audits times 2 months to ensure residents who have changes in their conditions receive treatment and care in accordance with professional standards of practice. 5. Audit results will be reviewed monthly by QAPI Committee.