Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for three residents, as evidenced by lack of pain monitoring, failure to schedule necessary pain management appointments, and improper administration of pain medications. One resident, following hospital discharge, was recommended to follow up with a pain management clinic and spine specialist. Although physician orders and a pain care plan were in place, there was no evidence that pain was monitored or recorded every shift, and the resident did not have a scheduled appointment with the pain specialist until after surveyor intervention. The resident continued to experience pain and was unaware of any scheduled follow-up, indicating a breakdown in communication and care coordination. Another resident was administered PRN pain medication even when their pain level was documented as zero, and there was no evidence that non-pharmacological interventions were attempted prior to medication administration. The physician's order did not include non-pharmacological interventions, and the Medication Administration Record did not reflect their use. The DON confirmed that pain medication should not be given when pain is absent and that non-pharmacological interventions should be implemented, but these standards were not followed. A third resident with chronic pain and opioid dependence had PRN orders for both acetaminophen and oxycodone without specific pain scale parameters. Review of records showed inconsistent pain management, with medications given for pain scores that did not align with best practices (e.g., oxycodone for a pain score of 1). There was also no documentation of non-pharmacological interventions prior to medication administration. Staff interviews confirmed that pain medications should be administered according to pain severity and that non-pharmacological interventions should be attempted and documented, but these practices were not consistently followed.