Failure to Provide Timely and Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident who required such services, as evidenced by multiple observations and interviews. The resident, who had limited physical mobility and a sacral wound, was observed on several occasions expressing significant pain, including verbal complaints of burning and screaming that could be heard in the hallway. The resident's son reported that the resident frequently complained of pain, especially when wet, and expressed dissatisfaction with the timeliness of care. On one occasion, the resident used the call bell due to pain but expressed fear that staff would not respond. Although a nurse responded within three minutes and acknowledged the resident's ongoing pain, it was revealed that the resident had not received their as-needed Tramadol for several days, despite ongoing complaints of pain. Review of the resident's care plan indicated that pain medication was to be administered as ordered, with effectiveness evaluated and side effects monitored. The care plan also specified offering pain medication prior to wound care and documenting and reporting pain complaints. However, the resident's pain was not managed according to these standards, as evidenced by the lack of timely administration of prescribed pain medication and insufficient evaluation of pain relief. Staff interviews confirmed that the resident was frequently in pain, and the care plan interventions were not consistently implemented.