Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with a history of cognitive impairment, dementia, a recent hip fracture and surgery, and other comorbidities. Despite documented orders and a care plan that included both pharmacological and non-pharmacological interventions for pain, staff did not consistently assess, implement, monitor, or revise pain management strategies as required. The resident frequently exhibited moderate to severe pain, both verbally and through non-verbal indicators such as restlessness, facial grimacing, and behavioral outbursts, yet there was repeated lack of documentation and evidence that appropriate interventions were provided. Records showed that the resident often had available PRN pain medications, such as Tylenol and Tramadol, which were not administered despite ongoing reports of pain. Non-pharmacological interventions, although listed in the care plan, were rarely documented as being attempted or implemented. When pain medications were administered and found to be ineffective, there was no evidence that staff consistently followed up with additional interventions or notified the physician in a timely manner. The resident's pain management regimen was not reassessed or adjusted despite ongoing reports of ineffective pain control and persistent pain behaviors. Interviews with staff, including nursing assistants, RNs, and the DON, confirmed that pain was not adequately managed and that staff did not always follow the facility's pain management policy. There were also missed opportunities to communicate pain management concerns to the physician or rounding providers, and staff did not consistently assess for pain when the resident exhibited behaviors that could be related to pain. The deficiency was further substantiated by the DON's confirmation of multiple instances where interventions were not implemented or documented, and where follow-up with the physician did not occur as expected.