Failure to Address Resident's Pain During ADL Care
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as Resident 65, during the provision of activities of daily living (ADLs) care. The incident involved a Certified Nursing Assistant (CNA 1) who did not recognize and address the resident's verbalization of pain while assisting with putting on socks. Despite Resident 65 expressing significant pain and requesting not to be touched, CNA 1 continued with the task, which led to the resident screaming and pulling away. CNA 1 acknowledged that the correct procedure would have been to stop the care and notify the Charge Nurse (CN) to administer pain medication. Resident 65 had a history of type 2 diabetes mellitus, long-term insulin use, and generalized muscle weakness. The resident was admitted to the facility with moderately impaired cognition and required assistance with various ADLs. The resident's care plan included specific interventions for pain management, such as administering pain medication as ordered and responding immediately to any complaints of pain. However, these interventions were not followed during the incident, as CNA 1 did not stop the care or notify the CN promptly. Interviews with the Licensed Vocational Nurse (LVN 9) and the Director of Nursing (DON) confirmed that the facility's protocol required CNAs to stop care and notify the CN when a resident verbalizes pain. The facility's policy on pain management emphasized recognizing pain through verbal and nonverbal cues and addressing it promptly. The failure to adhere to these protocols resulted in the resident experiencing unnecessary pain and discomfort, potentially affecting their quality of life.
Plan Of Correction
C. What measures will be put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: The Director of Staff Development/designee will re-educate the certified nursing assistants starting on 3/18/25 regarding the facility policy and procedures "Pain Assessment and Management" requirements for CNAs to report residents' complaints of pain when a resident has: 1. Non-verbal pain indicators, as patient applicable, 2. Verbal report of pain on a 1-10 pain scale where 10 is the most severe level of pain. The DSD, as part of the facility's new employee orientation, will educate certified nursing assistants on the facility policy and procedure for reporting residents' complaints of pain or observations of non-verbal indicators of pain to the charge nurse for management of resident pain. The charge nurse will evaluate residents' pain level each shift and provide pain medication as indicated. Each resident will be evaluated for pain at the time of admission, quarterly, annually, and with an exacerbation as well as each shift to ensure residents receive adequate pain management to reduce the potential for residents to refuse care related to discomfort. D. How the facility plans to monitor its performance to make sure solutions are sustained: The Director of Staff Development is responsible for monitoring certified nursing assistants' skill validation during new hire orientation, annually, and as needed when a variance to standard is identified in reporting a resident's verbal complaints of pain. Competency-related concerns identified by the DSD will be reported to the Director of Nursing for further review and instruction as indicated. The Director of Staff Development/designee will report significant trends identified in the DSD pain management skill reports to the QAPI/QAA Committee at least quarterly for the purpose of process improvement through root cause analysis and committee-recommended interventions to ensure continued compliance with this plan of correction; or for the purpose of terminating this plan of correction when substantial compliance has been achieved. Allegation Of Compliance Date: 3/25/2025. --- F755 Pharmacy Services Procedures Pharmacist/Records CFR(s): 483.45 (a)(b) (1)-(3) A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: 1. LVN 4 signed Resident 87 Clonazepam ODT 0.5mg at 1:40 pm, reconciling the narcotic log and remaining Clonazepam for Resident 87 on 2/25/2025. LVN 3 signed Resident 93's Lorazepam 1mg at 1:07 pm, reconciling the narcotic log and remaining Lorazepam for Resident 93 on 2/25/2025. LVN 3 and LVN 4 were re-educated by the Director of Nursing/designee on 2/25/2025 on the facility policy and procedure Administering Medications with emphasis on the standard of practice pour, pass, chart to ensure medications including controlled substances are signed, reconciled on the narcotic log, and medication administration record when the medication is administered. 2. LVN 6 administered Resident 347's Alprazolam on 2/25/2025. LVN 6 and LVN 7 were re-educated by the Director of Nursing/designee on 2/25/2025 on the facility policy and procedure assessing and administering as-needed medications when residents