Failure to Reassess and Update Care Plans for Pain Management
Penalty
Summary
The facility failed to reassess and reevaluate residents' needs and changes in condition, resulting in deficiencies in medication administration and care planning for two residents. In one instance, a nurse applied diclofenac sodium gel to both knees of a resident, despite the physician's order specifying application to both hands. Review of the resident's care plan revealed no documentation specifying which joints required pain management, nor any assessment regarding knee pain. The Director of Nursing confirmed that the care plan lacked details about pain in the hands or knees and that no assessment had been documented for knee pain. In another case, a nurse did not administer a resident's ordered diclofenac gel for right shoulder pain, as the resident had not requested it and reported no pain in the shoulder for at least two weeks. The nurse referenced the medication administration record, which showed a pain level of zero for the resident's shoulders. However, there was no reassessment of the resident's condition or notification to the physician regarding the change, and the care plan had not been updated to reflect the absence of shoulder pain. Facility policy requires care plans to be updated when there is a significant change in a resident's condition, but this was not done.