Failure to Manage Resident's Pain in a Timely Manner
Penalty
Summary
The facility failed to manage pain for one resident, resulting in unnecessary pain. Resident 224, who was admitted with diagnoses including difficulty walking, muscle weakness, asthma, and congestive heart failure, was found to have their call light device out of reach, preventing them from requesting pain relief. The resident expressed experiencing back pain and a desire for Tylenol, which was prescribed as needed for mild pain. The care plan for Resident 224 included keeping the call system within reach and responding promptly to pain complaints, but these interventions were not followed. Interviews with facility staff, including an LVN and the DON, confirmed the importance of addressing pain promptly and the potential consequences of not doing so. The facility's policy on pain management emphasized timely intervention to prevent increased pain severity. However, the failure to ensure the call light was accessible led to a delay in addressing the resident's pain, contrary to the facility's policy and the resident's care plan.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/4/25, Licensed Vocational Nurse (LVN) 5, administered two 325mg tablets of Tylenol pain medication to Resident 224. Pain medication was noted to be effective. On 3/4/25, Certified Nursing Assistant (CNA) 5, removed call light of the floor from behind Resident 224 bed and placed within reach of Resident 224. How do facility will identify other residents, having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/18/25, Social Service Director and Social Service Assistant conducted resident interviews to ensure residents' pain was being managed. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/24/25, the Director of Nursing in-serviced Nursing Staff, including, but not limited to LVNs and Registered Nurses (RNs) on the facility's policy and procedure titled, "Pain Management," with emphasis on the facility being responsible for helping the resident obtain or maintain their highest level of well-being while working to prevent or manage the residents' pain. The in-service also included nursing staff, implementing timely interventions to reduce the increase in severity of pain which included administering pain medication as ordered. Department Managers, including but not limited to Director of Staff Development, Social Services Director and assistant, Activities Director, Case Manager, Admissions Coordinator, Infection Preventionist, Minimum Data Set Nurse and MDSN Assistant, and Quality Assurance Nurse will conduct room rounds daily for five days weekly for two weeks in monthly thereafter to ensure resident's pain is being managed. How the facility plans to monitor its performance to make sure that solutions are maintained: The Administrator will review the Department Manager room rounds and will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for pain management with emphasis on administrating pain medication timely for three months or until compliance is met.