Failure to Notify Physician of Unrelieved Pain
Penalty
Summary
The facility failed to notify the physician regarding a resident's unrelieved pain, despite the resident having a history of pain related to internal orthopedic prosthetic devices and a right artificial hip joint. The resident was admitted with diagnoses that included these conditions and was assessed as having frequent, severe pain, with pain scores consistently reported as 9 out of 10. Orders were in place for acetaminophen for mild pain and oxycodone for moderate to severe pain, with clear instructions for administration based on pain levels. Despite these orders, the resident repeatedly reported severe pain that was not adequately relieved by the prescribed medications. Observations and interviews documented the resident moaning, grimacing, and expressing ongoing pain that interfered with mobility and participation in restorative activities. The resident's pain was not effectively managed, and staff, including the RNA and LVN, acknowledged the resident's persistent pain and inability to participate in therapy, but did not escalate the issue to the physician or the interdisciplinary team as required by facility policy. The licensed staff did not report the resident's uncontrolled pain to the physician, nor did they initiate a pain consultation, even though the resident's pain was not responding to the current interventions. The DON confirmed that the expectation was for staff to notify physicians of changes in condition, and the resident's physician stated he was not informed of the pain status. Facility policies required timely notification of changes in a resident's condition and reporting of unrelieved pain, but these procedures were not followed, resulting in the resident experiencing ongoing, unrelieved pain.