Failure to Assess and Document Pain Management per Care Plan
Penalty
Summary
A resident with a history of left leg amputation, COPD, and acute respiratory failure with hypoxia was observed wincing in pain while moving in bed and reported daily pain in the shoulder and hip, rating it between 5 and 8 out of 10. The resident stated that only Tylenol was being provided for pain and was unaware of the reason for this approach. Review of the resident's medical record revealed physician orders for both topical Biofreeze and oral acetaminophen for hip pain, as well as a care plan that required monitoring and recording of pain characteristics such as quality, severity, location, onset, duration, aggravating, and relieving factors. Despite these orders and care plan interventions, the record lacked documentation of regular pain assessments. During an interview, the DON acknowledged that pain should be assessed and documented for residents experiencing pain or receiving pain medication, but noted that the facility's EMR system had removed the pain assessment form, leaving them without a current method for documentation. The facility's pain management policy required recognition and management of pain consistent with the comprehensive assessment and plan of care, which was not followed in this instance.