Failure to Assess and Provide Pain Management for Resident with Acute Pain
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of acute pain due to trauma, osteoporosis with pathological vertebral fracture, and muscle weakness was not properly assessed or treated for pain. The resident, who was cognitively intact and required supervision for functional tasks, requested Tylenol for pain in the shoulders, hips, and back during the overnight shift. The nurse on duty denied the request, stating she did not believe the resident was in pain, and did not offer any alternative interventions. Documentation shows that the resident was not given any pain medication during that shift, and there was no use of a pain scale or nursing note to document the assessment. The resident later received Tylenol from the next shift nurse, at which time the pain was assessed as 8 out of 10. Review of the resident's physician orders at the time included scheduled and as-needed pain medications, as well as instructions for pain evaluation every shift. However, the Medication Administration Report did not reflect administration of pain medication or proper pain assessment during the shift in question. Additionally, the resident's care plan did not include a plan for pain management at the time of the survey. Interviews with facility staff confirmed that the nurse did not adequately manage the resident's pain according to facility policy and physician orders.