Failure to Care Plan for Chronic Pain Management
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive, person-centered care plan addressing chronic pain for a resident admitted with multiple diagnoses, including chronic pain, dependence on supplemental oxygen, heart failure, hypertension, major depressive disorder, and generalized anxiety disorder. Medical record review showed an active physician order for Hydrocodone-Acetaminophen to be administered twice daily for chronic pain. However, review of the resident's care plan revealed that no interventions or approaches for managing chronic pain had been included. This omission was confirmed during interviews with both the LPN/MDS Coordinator and the Director of Nursing, who acknowledged that the care plan lacked appropriate interventions for chronic pain and that it should have been addressed.