Failure to Use Appropriate Pain Assessment Tool for Nonverbal Resident
Penalty
Summary
The facility failed to accurately conduct a pain assessment for a resident with severe cognitive impairment and a history of dementia, bilateral osteoarthritis of the knee, and right knee contracture. During an observation and interview, a Licensed Vocational Nurse (LVN) attempted to assess the resident's pain using both English and Spanish, but the resident did not respond verbally or with gestures. The LVN stated that pain was determined by observing for grimacing or moaning. The resident's records indicated a lack of capacity to understand and make decisions, and a Brief Interview for Mental Status (BIMS) score of 00 confirmed severe cognitive impairment. Despite this, the resident's pain was documented using a numeric pain scale, which is not appropriate for nonverbal residents with advanced dementia. The Medication Administration Record (MAR) showed that pain levels were recorded using the numeric scale, and pain medication was administered based on these assessments. On one occasion, the LVN acknowledged that the PAINAD scale, which is designed for nonverbal individuals with advanced dementia, should have been used but was not. The Director of Nursing (DON) confirmed that the appropriate pain assessment tool was not utilized, as required by facility policy, which mandates the use of a standardized pain assessment instrument suitable for the resident's cognitive level.