Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with multiple serious diagnoses, including malignant neoplasm of the prostate, hemiplegia, and secondary malignant neoplasm of bone. The resident, who had moderate cognitive impairment, was observed exhibiting nonverbal signs of pain such as grimacing, wincing, and moaning while repositioning in bed. Despite a physician's order for Norco to be administered for moderate pain (pain level 4-6), the resident was not given the medication when his pain was recorded at a level 4. This was confirmed by a licensed nurse, who acknowledged that the medication was not administered as ordered for the documented pain level. Additionally, the resident's pain scores were frequently recorded at 7 or higher over several days, but there was no pain management regimen in place for severe pain (pain level 7-10). Nursing staff did not contact the resident's physician to review or adjust the pain medication orders despite repeated high pain scores. There was also no documentation of any communication with the physician regarding the need for a change in the pain management plan. Facility policy required systematic recognition, assessment, treatment, and monitoring of pain, including collaboration with the physician to develop and revise interventions as necessary. The policy also specified that staff should notify the practitioner if pain was not controlled by the current regimen. These procedures were not followed, resulting in the resident not receiving appropriate pain relief as required by both physician orders and facility policy.