Failure to Address Pain Management in Baseline Care Plan
Penalty
Summary
The facility failed to develop a baseline care plan that addressed pain and opioid pain medication for a resident who was admitted with multiple fractures following a fall. Physician orders included scheduled acetaminophen and as-needed oxycodone for pain, along with instructions to assess pain every shift using a numeric scale and document findings and interventions. Medication administration records confirmed that pain medications were given and pain assessments were documented. However, the baseline care plan created within 48 hours of admission only addressed activities of daily living and fall risk, omitting any mention of pain or pain management. Interviews with facility staff revealed that the MDS Coordinator and DON relied on the physician order summary as the initial care plan, which they believed included pain management. The MDS Coordinator acknowledged that pain and pain medication were not included in the baseline care plan due to a busy schedule. The DON stated that the order summary was used as the baseline care plan and was reviewed with the resident or representative, but pain was not specifically addressed in the care plan in progress. The facility Administrator confirmed that pain should have been addressed in the 48-hour care plan and was uncertain who would complete it if the MDS Coordinator was unavailable.