Failure to Communicate Pain Management Recommendations and Ineffective Pain Control
Penalty
Summary
The facility failed to implement its pain assessment and management policy for two residents by not communicating pain specialist recommendations to the medical doctor and by not notifying a physician when a resident's pain management was ineffective. For one resident with major depressive disorder and neuropathy pain, the pain specialist recommended attempting nonpharmacological interventions before administering medications and discontinuing Gabapentin. These recommendations were documented in progress notes but were not communicated to the attending physician, and there were no orders or documentation of nonpharmacological interventions being attempted. The resident reported that staff did not try any nonpharmacological interventions for their bilateral leg pain, and the nurse confirmed that the recommendations were not relayed to the physician as required. For another resident with end stage renal disease, Type 1 diabetes, and a recent myocardial infarction, pain management orders included Hydrocodone-Acetaminophen and Gabapentin. Despite ongoing reports of significant pain, with pain scores ranging from 6 to 9 out of 10 over several days, the resident stated that the pain medication was not effective and had informed nurses of this. The medication administration record showed persistent high pain levels, and there was no evidence that the physician was notified about the lack of pain control. A nurse acknowledged not contacting the physician due to being busy, despite recognizing that the pain management was not effective. Both cases demonstrated a failure to follow the facility's policy, which requires a multidisciplinary approach to pain management, including communication of recommendations and monitoring the effectiveness of interventions. The director of nursing confirmed that the pain specialist's recommendations and the resident's complaints should have been communicated to the attending physician, and that these omissions placed the residents at risk of not achieving optimal pain relief.
Plan Of Correction
F 697: Pain Management CORRECTIVE ACTION On 3/6/25, Resident 25 pain medication was reviewed, and non-pharmacologic intervention prior to administering pain medication ordered was given by MD. On 3/27/25, Resident 5 returned to the facility and pain assessment was reviewed and completed. OTHER RESIDENTS AFFECTED IDENTIFICATION On 3/27/2025, DON reviewed all orders for residents with pain management to ensure pain medications and non-pharmacologic intervention were performed prior to pain medication administration. No other resident was affected. 3/28/2025