Failure to Provide Effective Pain Management and Timely Provider Notification
Penalty
Summary
The facility failed to provide effective pain management, assess for pain, and report pain to the provider for two residents who required such services. For one resident with a history of stroke and right-sided spasticity, there were multiple documented instances of severe pain, including pain rated as high as 10 out of 10, facial grimacing, moaning, missed therapy sessions, and refusal to eat. Despite these clear signs of uncontrolled pain, there was no documentation that the provider was notified of the resident's increased pain until several days after the onset of symptoms. Pain assessments were inconsistently documented, and follow-up pain ratings after administration of PRN pain medications were not recorded, only noting whether the medication was effective. The resident's care plan included pain management as needed, but the interventions were not adequately implemented or communicated among staff, and therapy staff reported pain to nursing without evidence of timely provider notification or care plan adjustment. Another resident admitted for therapy following a left hip fracture did not receive a comprehensive pain assessment upon admission. The initial assessment only asked if the resident was experiencing pain at that moment and did not prompt further questions about pain history or potential for pain related to the hip fracture. The resident reported significant pain (rated 8 out of 10) on the first night, but no pain medication was ordered until the following day. Nursing staff did not report the resident's pain to the provider on the day of admission, resulting in a delay in pain management. The comprehensive pain assessment was not completed until seven days after admission, and follow-up pain ratings after PRN medication administration were not documented. The facility's pain management policy required pain assessments on admission, quarterly, with significant changes, and every shift, with provider notification as needed. However, these procedures were not followed for the two residents, leading to unmanaged pain, missed therapy, and decreased participation in activities of daily living. Staff interviews confirmed gaps in communication, documentation, and timely provider notification regarding residents' pain.