Failure to Provide Timely Pain Management and Assessment
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with a history of chronic pain conditions, including chronic obstructive pulmonary disease, below-knee amputation, muscle spasm, and neuropathy. Despite having a physician order for PRN Norco for pain and a care plan outlining pain management interventions, the resident repeatedly reported pain to nursing staff over a period of several weeks. Documentation showed multiple pain complaints, but there was no evidence of pain assessments or administration of the ordered pain medication during this time. The last recorded administration of Norco and pain assessment occurred several weeks prior to the resident's ongoing complaints. Interviews revealed that nursing staff were aware of the resident's pain complaints but did not perform pain assessments or administer the prescribed PRN pain medication. The resident expressed frustration, stating he had stopped reporting pain because staff did not respond to his requests, despite knowing he had an active order for pain medication. The DON confirmed that staff failed to follow expected procedures for pain assessment, documentation, and medication administration in response to the resident's reports of pain.