Failure to Assess and Manage Resident Pain Leading to Hospital Transfer
Penalty
Summary
A resident with a complex medical history, including left shoulder and arm pain, multiple sclerosis, spastic hemiplegia, polyneuropathy, and chronic pain, was admitted to the facility following a recent hospital stay for similar complaints. Upon admission, the resident reported new onset pain, and physician orders included as-needed oxycodone-acetaminophen for pain management. However, there was no documentation of further pain assessments or administration of pain medication on the day of admission, despite the resident's ongoing pain. Later that evening, during routine care, the resident expressed significant pain when repositioned by CNAs, who then returned her to a more comfortable position. The resident subsequently called 911 due to unresolved pain and left the facility against medical advice. Interviews with staff revealed that pain assessments were not conducted as required, and pain medication was not offered or administered, even though the resident was visibly in distress. The facility's pain management policy required pain assessment upon admission and during medication administration, but these procedures were not followed in this case.