Failure to Identify and Treat Resident Pain Following Surgery
Penalty
Summary
The facility failed to identify and treat pain for a resident following admission after spinal surgery. The resident had a history of pain in both hips and lower back related to surgery and post-surgical treatment. The care plan indicated the potential for post-surgical pain and called for administration of pain medication as ordered, with pain monitoring every shift and documentation of non-pharmacological interventions. However, the resident did not have any active pain medication orders, and the medication administration record showed no pain medication was given. Non-pharmacological interventions were also not documented as provided, and pain assessments were missed or not acted upon, even when the resident reported moderate to severe pain. Throughout several days, the resident reported increasing pain to nursing staff, including specific pain scores and descriptions of worsening symptoms affecting participation in physical therapy. Despite these reports, staff did not administer pain medication, offer non-pharmacological interventions, or notify the provider in a timely manner. The director of nursing confirmed that staff did not follow the facility's pain management policy, which requires provider notification and implementation of non-pharmacological interventions when pain is reported. Facility standing orders for pain management were requested but not provided.