Failure to Implement Effective Pain Management and Physician Notification
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with chronic conditions, including COPD and peripheral vascular disease. Despite physician orders for pain monitoring every shift and PRN acetaminophen for pain, staff did not consistently assess, monitor, or document the resident's pain levels and interventions. There were multiple instances where pain assessments were either not completed or not documented, and pain interventions were not recorded for moderate pain levels. Additionally, the resident's care plan did not address pain management, despite ongoing complaints and documented pain episodes. Throughout the resident's stay, there were repeated episodes of increased and unrelieved pain, with pain scores reaching as high as 10 out of 10. Staff administered acetaminophen as ordered, but when the medication was ineffective or the resident continued to report high pain levels, there was no documentation of physician notification or further action taken. On several occasions, staff noted that the PRN medication was not effective, yet did not escalate the issue or seek alternative interventions. Interviews with staff confirmed that pain complaints were often written down for the physician to review later, rather than being communicated promptly, and that the physician was not notified of acute changes in the resident's pain status. The physician and facility leadership confirmed that they were not made aware of the resident's ongoing pain issues or the ineffectiveness of the prescribed pain regimen. Staff interviews revealed a lack of adherence to the facility's pain management policy, which required assessment, documentation, care planning, and physician notification for unrelieved pain. The failure to accurately assess, monitor, address, care plan, and notify the physician of increased and unrelieved pain resulted in the resident experiencing ongoing pain without appropriate intervention.