Failure to Assess and Document Pain Management
Penalty
Summary
The facility failed to manage pain for one resident by not following its own pain assessment and management policy, as well as the resident's care plan. The care plan required licensed nurses to assess and document the resident's pain level on a 0-10 scale before and after administering pain medication, specifically oxycodone, for pain management. However, review of the medication administration records and progress notes showed that nurses did not document pain assessments before or after giving routine or as-needed pain medication. Additionally, when the resident complained of new abdominal pain, there was no documentation of the pain level, characteristics, or interventions provided to address the pain on the relevant dates. The resident involved had a history of a right femur fracture, was post-surgical for open reduction and internal fixation, and had other mobility issues. The resident was cognitively impaired and dependent on staff for most activities of daily living. Despite having physician orders for both scheduled and as-needed oxycodone for pain, there was no evidence that staff assessed or documented the resident's pain level or characteristics before or after medication administration, nor that pain medication was given in response to new complaints of abdominal pain. Interviews with nursing staff and the Director of Nursing confirmed that the expected practice was to assess and document pain levels before and after administering pain medication, and to address new onset pain as a change in condition. The facility's policy also required detailed pain assessments and documentation, including location, intensity, and characteristics of pain, as well as monitoring and reassessment after interventions. These practices were not followed, resulting in a failure to ensure proper pain management for the resident.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by the deficient practice: Resident #2 was transferred to the hospital on January 14, 2025, and is no longer residing at the facility. How the 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 March 27, 2025, the Medical Records Supervisor/designee reviewed pain level documentation for the 30 days prior, focusing on pre- and post-pain medication administration, to ensure no other residents were affected by this deficient practice. No additional findings were identified. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur: From March 24 to March 28, 2025, licensed nurses received in-service training conducted by the Administrator/designee. The training focused on pain management, including proper procedures and protocols for pain assessment and timely intervention, to prevent physical, mental, and emotional distress. The Medical Records Supervisor will conduct bi-weekly reviews of the Medication Administration Record (MAR) to ensure pain level documentation is completed both prior to and following the administration of pain medication. Any negative findings will be reported to the Director of Nursing (DON) during the daily clinical stand-up meeting to ensure timely identification and resolution of concerns. How the facility plans to monitor its performance to make sure that solutions are sustained: The DON/designee will provide any negative findings to the QAPI committee monthly for 3 months for further monitoring and action planning as indicated or until the QAA committee determines compliance. Date of Compliance: April 1st, 2025