Failure to Document and Monitor Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for one resident, as required by professional standards, facility policy, and physician orders. The facility's policy mandated that residents experiencing acute or significant changes in chronic pain be monitored at least each shift using standardized assessment tools. Physician orders for the resident included documenting verbal and nonverbal signs and symptoms of pain every shift and administering oxycodone three times daily for back pain. The resident, who had diagnoses including sciatica and mobility abnormalities and was moderately cognitively impaired, reported experiencing significant pain, particularly at night. Despite these requirements, there was no documented evidence of pain assessments or monitoring for the resident after a specific date. During interviews, facility leadership, including the NHA and DON, were unable to provide documentation showing that pain monitoring had been conducted as ordered. This lack of documentation and monitoring constituted a failure to follow both physician orders and facility policy regarding pain management.