Failure to Accurately Assess and Monitor Pain Management
Penalty
Summary
The facility failed to accurately assess and monitor pain for two residents who required pain management services. One resident, with chronic kidney disease, heart failure, and on hospice care, reported daily pain in multiple areas but stated that they only requested pain medication when the pain was unbearable due to staff being too busy. Documentation showed discrepancies in the number of as-needed pain medications administered and a lack of monitoring of pain characteristics as required by the resident's care plan. The pain monitor for this resident was discontinued in error, and there was no documentation of ongoing pain assessment in the electronic health record (EHR). Another resident with multiple chronic pain conditions, including spinal stenosis, degenerative disc disease, and fibromyalgia, reported chronic pain and ineffective pain management, particularly overnight. There was no provider order to monitor this resident's pain level, and no documentation of pain assessment was found in the progress notes. Staff interviews confirmed that pain monitoring was discontinued after seven days, and the DON stated that it was expected for staff to assess and document pain at least daily for residents experiencing pain.