Failure to Timely Communicate and Assess Resident Pain
Penalty
Summary
A deficiency occurred when a certified nurse assistant (CNA) failed to report a resident's complaint of a headache to a licensed nurse in a timely manner. The resident, who had a history of chronic pain syndrome, unclear speech, and severely impaired cognition, reported a headache to the CNA during morning care. The CNA did not inform the licensed vocational nurse (LVN) of the resident's complaint, as required by facility policy, because she became occupied with another resident and forgot to communicate the information. As a result, the LVN was unaware of the resident's pain until later in the day, which delayed assessment and potential pain relief for the resident. The resident's medical records indicated a history of chronic pain and significant cognitive impairment, requiring assistance with daily activities. Observations throughout the day showed the resident remained in bed with the call light within reach. Interviews with staff confirmed that the CNA did not report the headache to the LVN, and both the LVN and the Director of Nursing (DON) acknowledged that timely communication of pain complaints is necessary for proper assessment and intervention. Additionally, the facility failed to complete required quarterly pain risk assessments for the resident, as outlined in their pain management policy. The last documented pain risk assessment was several months overdue, and the DON confirmed that assessments should have been completed quarterly. The absence of these assessments meant the resident's pain status was not thoroughly evaluated as required by facility procedures.