Failure to Provide Comprehensive Pain Management and Assessment
Penalty
Summary
Facility staff failed to provide safe and appropriate pain management for multiple residents requiring such services, as evidenced by inadequate pain assessments, lack of comprehensive and individualized pain care plans, and insufficient monitoring and documentation of pain interventions. For several residents with chronic and acute pain, including those with complex medical histories such as palliative care, cancer, chronic pain syndromes, and neuropathy, the facility did not consistently assess pain using standardized tools, document pain characteristics, or follow up on the effectiveness of pain medications. In some cases, pain levels were not recorded before or after medication administration, and non-pharmacological interventions were either not offered, not documented, or not included in care plans. One resident with chronic pain and a history of palliative care experienced repeated episodes of severe pain, including a period when a scheduled Fentanyl patch was not administered as ordered, resulting in increased pain and the need for additional PRN opioid medications. Despite these events, there was no comprehensive pain care plan in place, and pain assessments were not consistently performed or documented during periods of increased pain. Staff interviews confirmed that pain management was largely reactive, with staff waiting for residents to request medication and not routinely assessing or documenting pain levels or the effectiveness of interventions. Other residents with chronic pain, cancer, or neuropathy also lacked individualized pain care plans, and their records showed inconsistent or absent documentation of pain assessments, non-pharmacological interventions, and monitoring for opioid side effects such as constipation and sedation. The facility's own policies required comprehensive, multidisciplinary pain management, including regular assessments, care planning, and monitoring for adverse effects, but these standards were not met for the residents reviewed. Staff and leadership interviews acknowledged these deficiencies, noting that pain assessments and care planning were not consistently completed or documented as required.