Failure to Reassess Pain After Hospitalization and Medication Changes
Penalty
Summary
The facility failed to comprehensively reassess a resident for pain management following a hospitalization related to concerns with her pain medication regimen and subsequent medication changes. The resident, who was cognitively intact and independent with most ADLs, had a history of chronic pain and was receiving multiple pain medications, including Buprenorphine, Oxycodone, Pregabalin, and Acetaminophen. Despite these interventions, the resident continued to report almost constant, severe pain that affected her sleep and daily activities. Documentation showed frequent use of PRN pain medications, and the most recent comprehensive pain assessment was dated over two months prior to the hospitalization and medication changes. After the resident's hospitalization for over-sedation and subsequent adjustments to her pain medications, there was no evidence in the electronic medical record of a comprehensive pain reassessment to evaluate the effectiveness of the new regimen or to consider additional interventions. Observations and interviews confirmed the resident continued to experience significant pain, and staff interviews indicated that comprehensive pain assessments were expected after a change in condition, such as hospitalization. However, the required reassessment was not completed, and the facility was unable to provide a policy on pain management when requested.