Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a newly admitted resident with multiple complex medical conditions, including heart failure, respiratory disease, several pressure ulcers, spinal and lumbar pain, adult failure to thrive, and urinary retention requiring a catheter. Upon admission, the resident's baseline care plan was not completed, and pain management needs, treatments, and goals were not assessed. Although the resident had physician orders for scheduled pain medications (Lyrica and acetaminophen), pain assessments were inconsistently completed, and non-pharmacological interventions were not documented or offered as required by facility policy. Throughout the resident's stay, documentation and direct observation revealed frequent and severe pain, with the resident repeatedly calling out and expressing that her pain was not being adequately managed. Staff interviews confirmed that non-pharmacological interventions, such as ice, heat, or distraction, were expected to be offered and documented, but these were not provided or recorded for the resident. The treatment administration record lacked evidence of attempted non-pharmacological pain interventions on multiple days, despite ongoing high pain scores and vocal complaints from the resident. Interviews with nursing staff and the assistant director of nursing indicated an awareness of the resident's persistent pain and the expectation to address pain within 15-20 minutes of notification, using both pharmacological and non-pharmacological methods. However, the resident's record showed that these expectations were not met, as non-pharmacological interventions were neither offered nor documented, and pain assessments were incomplete for one of the prescribed medications. Facility policy required staff to recognize, evaluate, and manage pain, but these steps were not consistently followed for this resident.