Failure to Implement and Document Pain Management Interventions
Penalty
Summary
The facility failed to implement comprehensive, person-centered care plans for four residents regarding pain medication administration. For each resident, although care plans were developed with specific interventions such as administering pain medications, monitoring and recording pain levels, and documenting effectiveness and side effects, there was no evidence in the medical records that these interventions were carried out. The residents involved had various diagnoses, including chronic pain, pressure ulcers, adult failure to thrive, and depression, with cognitive statuses ranging from intact to severely impaired. Despite care plans being in place and revised as needed, the required documentation and follow-through on pain management interventions were absent. Staff interviews confirmed these deficiencies, with a registered nurse acknowledging that pain was not documented as outlined in the care plans and that staff only verbally inquired about pain. The Assistant Director of Nursing stated that staff were expected to follow care plans, but the records did not reflect implementation of the pain management interventions. These findings were based on record reviews and staff interviews, as well as a community complaint regarding a resident not receiving pain medication despite reporting significant pain.