Failure to Provide Adequate Pain Management and Assessment
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with multiple chronic pain-related diagnoses, including polyneuropathy, osteoarthritis, myalgia, lumbago with sciatica, and osteoporosis. The resident was cognitively intact and consistently reported daily severe pain that interfered with mobility and participation in daily activities. Despite having orders for acetaminophen, ibuprofen, gabapentin, and a lidocaine patch, the resident continued to experience significant pain, which was not adequately controlled by the prescribed medications. The resident reported that the pain was never as low as a zero or three on the pain scale, and at times rated it above ten, even after receiving pain medication. The resident also expressed that the gabapentin made her tired without providing much relief, and she was unable to use her walker due to the pain, resulting in increased wheelchair use and decreased activity. Pain assessments and documentation were inconsistent and incomplete. The Medication Administration Record (MAR) showed that pain levels were not documented for most days, and when documented, did not reflect the resident's reported pain experience. Staff interviews revealed that pain assessments were often conducted as casual conversations rather than thorough evaluations, and sometimes were completed by referencing the resident's chart rather than direct interaction. The Care Plan Coordinator admitted to not conducting in-depth pain assessments and not always asking the resident the required questions. Nursing staff acknowledged the resident's ongoing pain complaints but expressed a lack of options for further pain management, with one nurse stating there was nothing more that could be done and another unaware of the resident's diagnoses. The facility's pain management policy required prompt and accurate assessment and management of pain, including consistent documentation and monitoring as the fifth vital sign. However, the facility did not follow these procedures, resulting in the resident experiencing uncontrolled severe pain, decreased mobility, and reduced participation in daily activities. The physician was unaware that pain assessments were not being completed as required and expected staff to document pain consistently. The failure to adhere to the facility's pain management policy and to respond appropriately to the resident's pain complaints led to the identified deficiency.