Failure to Notify Physician of Ineffective Pain Management
Penalty
Summary
The facility failed to notify a resident's physician of ongoing, inadequately controlled pain, as required by both facility policy and state regulations. The resident in question had a history of cognitive communication deficit, dementia, transient ischemic attack, and a hip joint replacement, and was admitted with orders for PRN Tylenol and Tramadol for pain management. Despite repeated documentation in the medical record of moderate to severe pain persisting after administration of these medications, there was no evidence that the physician was notified of the ineffective pain control during multiple instances over a period of several weeks. Facility policies required staff to inform the physician when pain was not adequately controlled and to consider revising the pain regimen. The resident's care plan also included interventions to evaluate the effectiveness of pain treatment and to report pain not at or below the resident's acceptable level to the physician. Progress notes repeatedly documented moderate to severe pain after PRN medications were given, with specific pain scores ranging from 5/10 to 10/10, and noted that both PRN Tylenol and Tramadol were ineffective at times. Despite these findings, there was no documentation that the physician was notified of the ongoing pain or that pain management was discussed, except for one instance where the physician was notified of behavior but not specifically about pain management. Interviews with nursing staff and the DON confirmed that the physician should have been notified when pain was not controlled by PRN medications, and that this notification did not occur as required. The deficiency was identified through record review and staff interviews, which established that the facility did not follow its own policies or regulatory requirements regarding physician notification for ineffective pain management.