Failure to Provide Effective Pain Management
Penalty
Summary
Facility staff failed to provide effective pain management for a resident who had recently undergone a cervical laminectomy and was experiencing frequent, severe pain. Despite multiple physician orders for pain medications, including acetaminophen, lidocaine cream, oxycodone, and Excedrin, the resident reported ongoing pain, often rating it between 7 and 9 out of 10 on the pain scale. Nursing progress notes and pain assessments documented repeated high pain scores, and the resident expressed dissatisfaction with the adequacy and timeliness of pain relief, including filing a formal grievance regarding these concerns. The facility's response to the grievance was limited to noting that pain medication was scheduled by the physician, with no additional interventions documented. Interviews with nursing staff and facility leadership confirmed awareness of the resident's frequent severe pain and the inadequacy of pain management. Staff acknowledged that pain levels above 5 or 6 should prompt further intervention, and both the unit manager and DON stated that the resident's pain should have been addressed sooner. The resident also reported that requests for pain medication were sometimes unmet, leading to frustration and feelings of neglect. The deficiency was further substantiated by the lack of timely escalation or adjustment of pain management strategies despite ongoing high pain scores and the resident's repeated complaints.