Failure to Provide Effective Pain Management
Penalty
Summary
The facility failed to provide effective pain management for a resident with a history of gout, back pain, peripheral vascular disease, and other conditions, who experienced unrelieved pain in the shoulder, neck, and legs. Despite physician orders for Lidocaine patches and Aspercreme for topical pain relief, these medications were not administered to the resident over several months as documented in the Medication Administration Record. The resident consistently reported severe pain, rating it as 8 out of 10, and expressed that the prescribed Tylenol was ineffective, leading to refusal of the medication and further requests for stronger pain relief, which were denied by the physician without documented rationale. Staff interviews and record reviews revealed that the resident's pain was not adequately assessed or managed according to the facility's policies. Pain levels were not consistently documented, and there was no evidence that the physician was informed when the resident reported severe pain or when pain management interventions were ineffective. The Interdisciplinary Team did not convene with the resident and family to address ongoing pain management issues or the resident's refusal of pain medication. Additionally, the facility did not notify the Medical Director when the attending physician refused to prescribe stronger pain medication. As a result of unmanaged pain, the resident frequently refused activities of daily living, restorative nursing assistant services, and participation in facility activities. Staff noted that the resident's pain led to agitation, refusal of care, and a desire to leave the facility. The facility's failure to follow physician orders, assess and document pain appropriately, and involve the care team in addressing pain management contributed directly to the resident's ongoing discomfort and decreased participation in necessary care and activities.