Failure to Provide Consistent Pain Management
Penalty
Summary
A deficiency was identified when a resident with multiple medical conditions, including a history of transient ischemic attack, cerebral infarction, protein-calorie malnutrition, major depressive disorder, chronic obstructive pulmonary disease, cognitive communication deficit, and chronic knee instability, did not receive appropriate pain management as per her care plan and provider orders. The resident had a documented history of moderate cognitive impairment and consistently reported pain levels between 3-6 out of 10, with recent assessments indicating pain as high as 8 out of 10. Despite having scheduled and PRN orders for pain medications such as Oxycodone, Ibuprofen, and Tylenol, the resident did not receive her scheduled Oxycodone doses on two consecutive days, and there was no evidence of PRN pain medication administration during the month reviewed. Staff interviews revealed that the resident had not received her pain medication on the mornings in question, and the LPN responsible cited reasons such as the resident being asleep or refusing medication, but there was no documentation of re-attempts or provider notification as required. The resident herself reported significant pain and a preference for her pain level to be at or below 3 out of 10, but her pain was not adequately addressed. The MARs confirmed the lack of administration of both scheduled and PRN pain medications, and staff failed to document their actions or notify the provider when medications were missed or refused. The facility's pain management policy requires regular assessment, prompt response to pain complaints, and documentation of interventions, but these procedures were not followed. The DON and other nursing staff confirmed that pain medications should have been administered when the resident verbalized pain and that refusals or missed doses should be documented and reported. The lack of adherence to these protocols resulted in the resident experiencing poorly controlled pain, as evidenced by her own reports and staff observations.