Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for two residents requiring such services. One resident, who was non-verbal, bedbound, and had significant contractures to both hands, was observed without prescribed hand splints or hand rolls on multiple occasions. During passive range of motion (PROM) exercises, the resident exhibited clear signs of pain, such as deep facial grimacing and tightly closed eyes, yet was not pre-medicated for pain prior to the intervention. The staff member performing PROM acknowledged the resident's pain but continued the exercise until stopped by the surveyor. It was also found that the resident did not have any pain medication ordered prior to the incident, and staff were not consistently following care plan interventions for pain assessment and management. Another resident, whose preferred language was Vietnamese, was not assessed for pain in a manner she could understand. Despite her repeated attempts to communicate pain using picture cards and the Vietnamese word for pain, staff relied solely on the absence of facial grimacing to assess her pain level. The Wong-Baker Faces Pain Rating Scale, which should have been available for non-English speaking residents, was not present at the bedside, and staff were unfamiliar with the available picture cards. Pain assessments were consistently documented as zero, and pain medication was administered without proper assessment or communication with the resident in her preferred language. Both cases demonstrate a failure to accurately assess, monitor, and manage pain according to the residents' needs and care plans. The facility did not ensure that staff were adequately trained or equipped to recognize and respond to non-verbal or culturally specific expressions of pain, resulting in inadequate pain control and failure to maintain the residents' highest practicable level of well-being.