Failure to Assess and Manage Severe Pain in Cognitively Impaired Resident
Penalty
Summary
The facility failed to adequately assess and manage pain for a resident with severe cognitive impairment, chronic pain, and significant physical limitations. The resident had a history of osteoarthritis, hemiparesis, and chronic pain, and was dependent on staff for all activities of daily living. Despite care plan directives to evaluate pain interventions, provide both pharmacological and non-pharmacological pain relief, and notify the physician if interventions were ineffective, staff did not consistently follow these protocols. Documentation showed that the resident experienced episodes of uncontrolled crying, poor oral intake, and visible distress over several days, but there was a lack of follow-up assessment or timely action to address ongoing pain. The resident's medication orders included both scheduled and as-needed acetaminophen and hydrocodone-acetaminophen for pain management. However, when as-needed acetaminophen was found to be ineffective, there was no evidence that alternative pain management strategies were implemented or that the physician was promptly notified. Additionally, there was a lapse in the availability of the resident's scheduled hydrocodone-acetaminophen due to a delay in obtaining a new prescription, further contributing to inadequate pain control. Communication between nurses, physicians, and other healthcare providers regarding the resident's pain was insufficient, as critical information was not consistently documented in the electronic health record or the Team Health Book. Staff interviews revealed that while some aides reported the resident's pain to nurses, and nurses were aware of increased pain, documentation and follow-up actions were inconsistent or lacking. The resident's pain assessments on the treatment administration record often indicated no pain, despite clear behavioral signs and staff observations of distress. Ultimately, the resident was found to have an acute, displaced fracture of the left humerus, which had not been identified on earlier X-rays, and had experienced ineffective pain relief for six days prior to the diagnosis. The facility's failure to assess, document, and manage the resident's pain according to professional standards and the care plan resulted in prolonged suffering and placed the resident at risk for further decline.