Failure to Appropriately Monitor and Assess Pain Complaints
Penalty
Summary
The facility failed to appropriately monitor and comprehensively assess pain complaints for a resident with a complex pain history. The resident had diagnoses including fibromyalgia, chronic pain, diabetes, neuropathy, restless leg syndrome, depression, and psychotic disorder, and was prescribed both scheduled and PRN pain medications, as well as non-pharmacological interventions. The resident's care plans and assessments indicated frequent pain that affected sleep and daily activities, and the resident was able to verbalize pain and pain relief. Despite these interventions, documentation and monitoring of pain were inconsistent. Review of the resident's medication administration records and progress notes revealed that pain ratings and pain locations were often missing when PRN pain medications were administered. Specifically, several instances were noted where pain ratings or locations were not documented, and there was a lack of follow-up after pain medication administration. Additionally, the resident reported ongoing severe pain, rating it as eight or nine out of ten, and stated that pain medications were not effective and that nurses did not return to reassess pain after administration. Staff interviews confirmed that pain assessments were not always completed or documented as required, and follow-up on resident complaints was lacking. The facility's pain management policy required ongoing pain assessment, documentation of pain characteristics, and monitoring the effectiveness of interventions. However, the records showed that pain assessments were not consistently performed or documented, and there was insufficient evidence of comprehensive pain monitoring. This failure to follow policy and ensure thorough pain assessment and documentation led to the deficiency identified during the survey.