Failure to Provide Consistent and Effective Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for two residents requiring such services, resulting in deficiencies related to the evaluation, administration, and documentation of pain management. For one resident, a female with chronic pain syndrome and multiple bone disorders, the facility did not evaluate the effectiveness of her current pain medications and failed to have her prescribed pain medications available for administration. Upon admission, her pain was assessed at a level of 4/10, and she was prescribed a Fentanyl patch, Baclofen, and PRN oxycodone. However, the Fentanyl patch was not reordered in a timely manner due to a lack of follow-up by the admitting nurse, resulting in a period where the resident did not have access to her prescribed pain management. The resident reported severe pain, delays in receiving PRN medication, and expressed a preference for routine rather than PRN administration. Additionally, her baseline care plan did not include any entries related to pain or pain management, and staff interviews confirmed that the lack of a care plan could lead to inadequate pain management. For the second resident, a male with metabolic encephalopathy, dementia, pain, and a history of right shoulder surgery, the facility failed to conduct at least daily assessments of pain for 34 out of 49 days. Although his care plan identified the presence of pain and included interventions to evaluate pain using a 1-10 scale, it did not specify the frequency of assessments. There was no physician order for pain monitoring, and documentation of pain assessments was missing for numerous days. Observations and interviews revealed that the resident experienced ongoing pain, reported that pain medications were not effective, and was unable to recall details of conversations about his pain. Nursing staff confirmed that pain monitoring was not consistently documented and that there was no standing order to monitor pain, despite the resident's chronic pain condition. The facility's own pain management policy required pain assessments every shift and as needed, with documentation of pain levels and effectiveness of interventions. However, both residents experienced lapses in pain assessment, documentation, and timely administration of pain medications, contrary to professional standards of practice, the comprehensive person-centered care plan, and the residents' expressed choices. These failures were confirmed through record reviews, staff and resident interviews, and direct observations.