Failure to Reassess and Appropriately Manage Resident Pain
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident by not conducting a comprehensive reassessment of the resident's pain status and prescribed PRN medications, as required by facility policy. The resident, who had diagnoses including dementia and pulmonary hypertension, was admitted with no reported pain and was not on scheduled pain medication. However, after the onset of pain, there was no documented evidence that a comprehensive pain assessment was completed to identify the cause of pain or to develop an individualized pain management plan. Despite having a care plan that included monitoring and evaluating pain interventions, staff administered narcotic pain medication outside of the prescribed parameters. Specifically, Morphine Sulfate, which was ordered for pain levels 6-10 or for shortness of breath, was given multiple times for pain levels of 4-5 and without evidence of shortness of breath. Additionally, after the physician changed the order to indicate use only for shortness of breath, staff continued to administer the medication without documentation of this symptom. There was no evidence in the clinical record that the facility evaluated the cause of the resident's pain, reassessed the appropriateness of PRN medications, or modified the care plan in response to the resident's emerging symptoms. The Director of Nursing confirmed that a comprehensive pain assessment was not completed as per policy, and that narcotic medication was administered without proper indication or reassessment. This resulted in a failure to ensure that pain management was based on comprehensive reassessment and the individual needs of the resident.