Failure to Provide and Document Non-Pharmacological Pain Interventions
Penalty
Summary
The facility failed to implement and document non-pharmacological pain management interventions as ordered for a resident with a complex medical history, including cauda equina syndrome, spinal stenosis, chronic pain, and recent back surgery. Physician orders specified the use of ice packs to the surgical incision for pain relief multiple times daily, but the care plan did not detail these interventions, and administration records lacked documentation of their use. The resident, who was cognitively intact and able to express needs, reported not receiving non-pharmacological interventions such as ice packs between scheduled pain medications, despite repeated requests and physician instructions. Observations and interviews confirmed that the resident experienced significant pain and that ice packs were not provided as ordered, with staff indicating that the resident had to request them rather than receiving them routinely. The DON verified that the medical record did not reflect the provision of ice packs and that the care plan did not include this intervention. The facility's pain management policy required incorporation of pain interventions into the care plan and revision if pain was not adequately controlled, but these steps were not followed for this resident.