Failure to Provide Appropriate Pain Management
Penalty
Summary
A resident with diagnoses including Alzheimer's disease, anxiety disorder, and weakness, and who was assessed as severely cognitively impaired, was identified as requiring scheduled pain management. The resident's care plan directed staff to attempt three non-pharmacological interventions before administering as-needed (PRN) pain medication, to administer medications as ordered, and to evaluate the effectiveness of pain interventions. Despite these directives, the resident verbally expressed pain multiple times during meals, in the presence of staff including a Licensed Practical Nurse and Certified Nursing Assistants. The clinical record for the day in question did not document any pain assessment, interventions, or administration of pain medication, even though an order for PRN acetaminophen was in place. Staff interviews confirmed that the expectation was for aides to notify a nurse if a resident reported pain, and that pain relief options such as Tylenol or muscle rubs could be provided. The facility's pain assessment policy required thorough assessment and interventions to alleviate pain. However, there was no documentation that staff assessed the resident's pain or implemented any interventions on the day the resident reported discomfort, indicating a failure to follow the care plan and facility policy for pain management.