Failure to Use Appropriate Pain Assessment for Cognitively Impaired Resident
Penalty
Summary
Facility staff failed to utilize an appropriate pain assessment tool based on a resident's cognitive status. The resident in question had a history of abnormal weight loss and senile degeneration of the brain, was admitted as a hospice respite patient, and was documented as being very confused and not easily redirected. Despite having as-needed orders for Tylenol and Morphine for pain, there was no documentation indicating administration of Tylenol or Morphine on the MARs, and the pain monitoring documentation lacked clarity regarding the basis for the recorded pain assessment numbers. Pain assessments were inconsistently completed, with one assessment noting multiple pain indicators but then indicating the resident could not communicate pain location or characteristics. Subsequent assessments inappropriately skipped staff assessment for pain, despite the resident's inability to communicate effectively. Review of the facility's pain management policy revealed that staff were required to use a pain assessment tool appropriate for the resident's cognitive status and to reassess pain management at established intervals. However, when Morphine was administered, there was no evidence that a pain assessment was completed before or after administration to evaluate effectiveness, as confirmed by the ADON. No additional pain assessments were provided to the surveyor, and the documentation did not support that pain was being adequately assessed or managed for this resident.