Failure to Provide Adequate Pain Management and Non-Pharmacological Interventions
Penalty
Summary
The facility failed to provide adequate pain management for a resident with a history of significant injuries and ongoing pain. The resident, who was cognitively intact and had diagnoses including injuries from a motor vehicle accident, intervertebral disc degeneration, and chronic back pain, did not have a pain assessment documented in the Minimum Data Set (MDS). The electronic medical record (EMR) included orders for pain medications and required pain monitoring every shift, but there was no evidence that pain monitoring was consistently documented. Additionally, the EMR lacked documentation of non-pharmacological pain interventions being offered or their effectiveness, and the pain assessment form left the section for non-medication interventions blank. Observations and interviews revealed that the resident experienced visible and severe pain, reported that prescribed medications were not effective, and stated that staff did not respond adequately to her pain complaints. Staff interviews confirmed that pain levels were not routinely assessed and that non-pharmacological interventions were not being used. The facility's policy indicated that non-pharmacological interventions should be considered, but these were not implemented for the resident in question. The care plan included some interventions, such as positioning with pillows and administering pain medication, but did not address the lack of consistent pain monitoring or the use of alternative pain relief methods.