Failure to Provide Ongoing Pain Assessment and Timely Intervention for Nonverbal Resident
Penalty
Summary
A resident with severe cognitive impairment and a history of Alzheimer's disease, thoracic spine pain, and chronic pain was not provided with ongoing pain assessments or timely interventions when exhibiting signs of pain. The resident was dependent on staff for all activities of daily living and communication of needs, as indicated in her care plan. Despite being on a scheduled regimen of pain medications, including fentanyl patches, oxycodone, and acetaminophen, there was no documentation of as-needed (PRN) pain medications being administered during the review period, nor were regular pain assessments recorded in the progress notes. Observations revealed that the resident frequently exhibited non-verbal signs of pain, such as loud moaning, which were audible from the hallway. Staff, including agency nursing assistants, were seen passing by or briefly entering the resident's room without providing pain interventions or conducting assessments. Interviews with staff indicated a lack of familiarity with the resident's pain behaviors and an absence of nonpharmacological interventions. The nurse on duty confirmed that pain assessments were not routinely completed, and the last recorded pain score was several months prior. The facility's policy required weekly pain assessments for residents with stable chronic pain and more frequent assessments for acute pain. However, the assistant director of nursing acknowledged that there was no process in place to ensure regular pain assessments for nonverbal residents on scheduled pain medications. The lack of timely assessment and intervention for the resident's pain, despite clear signs and a documented need, led to the deficiency.