Failure to Provide Timely and Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for two residents, resulting in deficiencies related to pain assessment and timely administration of pain medication. One resident, admitted with multiple fractures and osteoarthritis, had a care plan indicating the need for pain medication before therapy and as needed for pain. Despite this, the resident reported severe pain in the morning, rated as 10 out of 10, and stated that they had been requesting pain medication since waking. The resident was observed in discomfort and unable to participate in therapy exercises due to pain. The nurse confirmed that the resident had not been assessed or given pain medication, and the occupational therapist had not communicated the resident's pain to nursing staff. Another resident with chronic pain conditions, including intervertebral disc degeneration, rheumatoid arthritis, and osteoarthritis, was observed in visible distress, moaning and expressing pain. The resident's scheduled pain medications, including opioids and other analgesics, were not administered at the prescribed times. Staff interviews revealed that the nurse had not been able to administer any scheduled morning medications, and the resident continued to experience pain for an extended period. The delay in medication administration was confirmed by both the resident's family and staff, and the facility's medication administration audit showed that medications were given significantly later than scheduled. Both cases demonstrated a lack of timely pain assessment and intervention consistent with the residents' care plans and professional standards of practice. The facility's own policies required pain management and medication administration within specific timeframes, but these were not followed, resulting in unmanaged pain and discomfort for the affected residents.