Failure to Provide Timely and Effective Pain Management
Penalty
Summary
A resident with a history of peripheral vascular disease, cellulitis, systemic lupus erythematosus, osteoarthritis, and spinal stenosis experienced ongoing pain that was not effectively managed by the facility. The resident reported a jabbing pain and expressed that the prescribed opioid pain medication was ineffective, preferring acetaminophen instead. Despite these complaints, the resident did not receive acetaminophen and reported delays in receiving pain medication. Documentation showed that the resident's pain was rated as high as 8 out of 10, and the resident was cognitively intact, able to clearly communicate pain and preferences to staff. Staff interviews and record reviews revealed that the assigned LPN was aware of the resident's complaints about the ineffectiveness of the opioid medication and had attempted to notify the physician, but the message did not go through and no follow-up occurred. The Medication Administration Record indicated that pain assessments were inconsistently documented, with staff sometimes recording low pain scores despite resident reports of significant pain. Non-pharmacological interventions were not attempted or documented, and the care plan interventions for pain management were not fully implemented, including timely physician notification and use of alternative pain management strategies.