Failure to Provide Pain Management Evaluation
Penalty
Summary
The facility failed to provide a pain management evaluation for a resident with multiple diagnoses, including unspecified dementia, anxiety, primary osteoarthritis of both knees, and hypertension. The resident was noted to have moderate cognitive impairment and was dependent on staff for most activities of daily living. Physician orders included scheduled and as-needed pain medications, and the care plan directed staff to acknowledge pain, use non-pharmacological interventions, administer pain medication as ordered, and notify the provider if pain was not adequately controlled. Despite these orders, pain monitoring records showed the resident repeatedly reported moderate pain levels in the knees, with no documented administration of as-needed acetaminophen during the month reviewed. Progress notes indicated a referral to pain management was planned, but interviews with staff revealed that the referral was not completed and the resident had not been evaluated by a pain specialist. The DON confirmed that the resident should have been seen for pain management but was unsure why this had not occurred. The facility's policy required pain screening, evaluation, and referral to other disciplines as needed, but this process was not followed for the resident, resulting in unaddressed and unmanaged pain.