Deficiency in Pain Management for a Resident
Penalty
Summary
The facility failed to provide appropriate pain management interventions for Resident R48, who was admitted with diagnoses including COPD, contracture of the left knee, and osteoarthritis of the right shoulder. Despite the resident's comprehensive care plan indicating a risk for alterations in functional mobility due to contracture deformity, there was no documented evidence of a care plan specifically addressing pain management. The resident, who is cognitively intact with a BIMS score of 12, reported experiencing significant pain when rolled to the right side and had communicated this discomfort to multiple staff members. Interviews with the Clinical Regional Nurse confirmed that the resident expressed pain related to the contracture on the right side, which increased when rolled to that side. Despite this, the clinical record included a task for the resident to be rolled to both the left and right sides every 2-3 hours, without any adjustments to prevent rolling onto the painful side. This lack of a tailored care plan and failure to heed the resident's expressed pain and preferences led to the deficiency in pain management services.
Plan Of Correction
A - Resident R48 plan of care and point of care were updated at the time noted to ensure turn and reposition avoids the right side. B - Audit of all residents with turn and reposition programs to ensure resident has no pain with turning with care plan updated as appropriate. C - All nursing staff educated to monitor for signs of pain with repositioning resident and avoid positions that cause pain to the resident. D - Weekly x 4 then monthly x 2 audits by DON or designee of residents with positional pain for pain management. Results discussed during QAPI meetings.