Failure to Assess and Document Pain Management for Resident with Fracture and Dementia
Penalty
Summary
A deficiency occurred when the facility failed to properly assess and manage pain for a resident with a history of right femur fracture, dementia, osteoarthritis, and impaired mobility. The resident's care plan required staff to administer analgesic medication as ordered, anticipate pain relief needs, and respond immediately to any complaints of pain. Physician orders specified that licensed staff should monitor the resident's pain level using a 0-10 scale every shift and administer Hydrocodone-Acetaminophen as needed for moderate to severe pain. On one occasion, the resident complained of persistent pain in the right lower extremity during a physical therapy session. The physical therapist documented the complaint and informed the licensed nurse, who agreed to monitor the resident. However, there was no evidence in the Medication Administration Record (MAR) that the resident received pain medication before or after the therapy session, nor was there documentation of a pain assessment on that day. Additionally, when pain medication was administered on subsequent dates for moderate to severe pain, the location of the pain was not documented by the licensed nurse, contrary to facility policy and care plan requirements. Interviews with nursing staff confirmed that pain location and assessment details were not consistently documented, and the responsible nurse acknowledged failing to record the pain location when administering medication. The facility's policies required thorough pain assessment, including location, intensity, and onset, as well as documentation and follow-up. The lack of assessment and documentation had the potential to result in unrelieved or uncontrolled pain for the resident.