Failure to Provide Adequate Pain Management and Develop a Person-Centered Pain Care Plan
Penalty
Summary
A resident with a history of chronic embolism and thrombosis of the lower extremities experienced ongoing pain, fluctuating between 5 and 8 out of 10 on the pain scale, primarily in the bilateral anterior thigh radiating to the lower extremities. The resident reported that the prescribed pain medication, acetaminophen, was not effective in relieving the pain, which impacted daily activities and participation in group and social events. Staff interviews confirmed that the resident frequently requested pain medication, particularly in the mornings, and that the frequency of PRN acetaminophen administration had increased significantly from 4 doses in February to 28 doses in April. Record reviews and staff interviews revealed that despite the increased use of PRN pain medication and the resident's ongoing complaints of pain, there was no evidence that the effectiveness of the pain management regimen was evaluated or that the physician was notified about the lack of pain control, as required by facility policy. Both the licensed nurse and the DON acknowledged that the increase in PRN medication indicated ineffective pain management, and that the physician should have been notified to consider alternative or routine pain management strategies. The facility's pain management policy specifically required physician notification and reassessment when pain control was inadequate. Additionally, the resident did not have a comprehensive, person-centered care plan addressing pain management, despite being prescribed pain medication and having active pain symptoms. Staff confirmed that the absence of a care plan for pain meant that measures to manage the resident's pain and discomfort were not identified or implemented. The DON acknowledged that this failure was not in accordance with facility policy, which required individualized care plans for residents experiencing pain, including specific interventions and measurable objectives.