Failure to Provide Effective Pain Management and Timely Assessment
Penalty
Summary
A deficiency occurred when staff failed to adequately reassess, report, or provide effective pain management for a long-term resident who was mildly cognitively impaired. The facility's policy required staff to identify situations that increase pain, understand the rationale for pain medication, and document pain levels when pain increases. Despite this, the resident repeatedly expressed significant pain, particularly in the gluteal region, during routine activities such as repositioning and peri-care. Observations showed the resident attempting to reposition themselves, vocalizing pain, and reporting high pain scores, yet staff did not consistently assess or respond to these complaints as required. Interviews with staff revealed that pain assessments were only being conducted weekly rather than before and after medication administration, contrary to facility policy. The medical provider was not informed of the resident's increased pain, and pain assessments were not documented following administration of scheduled pain medication. Physical observations later revealed red areas and an open wound on the resident's buttocks, indicating ongoing discomfort and lack of effective pain management. Staff acknowledged that complaints of pain were not always followed by appropriate assessment or notification to the provider.