Failure to Provide Timely and Appropriate Pain Management
Penalty
Summary
A resident with a complex medical history, including chronic pain syndrome, osteoarthritis, sciatica, recent fractures, and a recent surgery to the left leg, was readmitted to the facility following a hospital stay. Upon readmission, the resident's pain management orders from the hospital, which included acetaminophen-hydrocodone for moderate and severe pain, were not continued. Instead, the only pain medication available was acetaminophen, which was insufficient for the resident's reported pain levels. The resident repeatedly verbalized severe pain and expressed that the acetaminophen was not effective, but no stronger pain medication was provided until the following day. Facility staff failed to adequately assess, treat, and document the resident's pain in accordance with the facility's pain management policy. Multiple staff members, including a treatment nurse and an LVN, did not assess the resident's pain level during care interactions, despite clear verbal and non-verbal indications of severe pain. The resident reported a pain level of 10 out of 10 and described significant distress, including sleeplessness and feelings of hopelessness, yet staff did not promptly notify the physician or obtain appropriate pain management orders in a timely manner. Documentation showed that the resident's care plan included interventions to anticipate and respond to pain, but these were not effectively implemented. The medication administration record did not reflect appropriate pain medications for moderate or severe pain until after a significant delay. The deficiency resulted from the facility's failure to identify, assess, and manage the resident's pain as required by policy, leading to prolonged and unrelieved pain for the resident.