Failure to Develop Comprehensive Pain Management and Opioid Use Care Plan
Penalty
Summary
The facility failed to develop an individualized, person-centered comprehensive care plan addressing pain management and opioid use for a resident with multiple fractures and chronic pain. The resident was admitted with significant injuries, including fractures of the clavicle, pelvis, hip, and leg, and had a diagnosis of chronic pain. Medication orders included scheduled doses of Methadone, Cyclobenzaprine, Gabapentin, and as-needed Tylenol for pain. Despite these orders and the resident's ongoing need for pain management, a review of the comprehensive care plan did not show any interventions or plans related to pain management or opioid medication use. Further review of the resident's Minimum Data Set (MDS) assessment confirmed that the resident had moderately impaired cognition and was receiving scheduled opioid and pain medications. Medication administration records indicated that all scheduled doses were given except for one missed dose of Methadone. Interviews with the MDS Nurse and Regional MDS Coordinator confirmed that the care plan should have included pain management and opioid use, but this was overlooked. The Administrator also acknowledged that the care plan was expected to reflect the resident's clinical condition and care needs, including pain management and opioid use.