Failure to Provide Effective Pain Management and Documentation
Penalty
Summary
Facility staff failed to provide effective pain management for a resident who reported pain levels of 4 out of 10 on two consecutive days. Despite physician orders to administer acetaminophen for mild pain and to use non-pharmacological interventions such as heat, repositioning, relaxation breathing, food/fluids, massage, exercise, and immobilization, there was no documentation that these interventions were provided. Additionally, the resident's pain was not thoroughly assessed or reassessed after the initial complaint, as required by both physician orders and facility policy. The resident involved had diagnoses including lack of coordination and hypertensive heart disease, and required substantial assistance with activities of daily living. The resident was cognitively intact and able to communicate pain. Facility records, including the Medication Administration Record and Medication Administration Notes, did not show evidence of pain assessments, administration of pain medication, or implementation of non-pharmacological interventions on the dates in question. Interviews with the DON confirmed the lack of documentation and intervention following the resident's pain reports.