Failure to Develop and Implement Comprehensive Pain Management Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan addressing pain management for a resident with a history of stroke, chronic pain syndrome, opioid abuse, anxiety, and depression. Upon admission, the resident's Minimum Data Set (MDS) assessment indicated the presence of ongoing pain, with the resident rating their pain as 8 out of 10. The assessment also revealed that pain occasionally interfered with sleep, rarely affected therapy, and frequently limited daily activities. The Care Assessment Area (CAA) for pain was triggered, indicating the need for a care plan focus on pain management. Despite these findings, a review of the resident's care plan showed that no focus area for pain had been included as of several weeks after admission. Interviews with facility staff, including a registered nurse and the Director of Nursing, confirmed that the care plan did not address pain management until the day of the surveyor's inquiry, despite the resident's ongoing pain and relevant diagnoses. This omission was not in accordance with the facility's policy, which requires the development of a person-centered care plan with measurable objectives and timeframes for all identified needs.