Failure to Provide Comprehensive Pain Assessment and Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with systemic lupus erythematosus and poly-osteoarthritis, both conditions associated with acute and chronic pain. The resident's care plan included interventions such as education on pain management, use of non-pharmacological and pharmacological interventions, and monitoring the effectiveness of pain medications. Physician orders were in place for acetaminophen for mild pain and oxycodone for more severe pain, with instructions for administration as needed. On a specific day, the resident reported increasing lower back pain, was tearful, and had a low-grade fever. Nursing documentation indicated that acetaminophen was administered for fever, and the physician was notified. However, there was no documentation of a comprehensive pain assessment at that time, nor was there a numerical pain scale rating or detailed characterization of the pain. Despite multiple complaints of pain and administration of both acetaminophen and several doses of oxycodone, the clinical record did not reflect pain assessments prior to or after medication administration, nor did it document the effectiveness of the interventions provided. Interviews with the resident confirmed ongoing and severe pain that was not adequately assessed or managed by staff, and the Nursing Home Administrator acknowledged the lack of comprehensive pain assessment and documentation. The facility's failure to assess, monitor, and document pain management interventions was not consistent with professional standards of practice or the facility's own pain management policy.