Failure to Develop and Implement Effective Pain Management Plan
Penalty
Summary
The facility failed to develop and implement an effective pain management regimen for a resident with significant pain-related diagnoses, including neuropathy, above-the-knee amputation, and chronic foot ulcers. The resident's care plan identified acute pain and set a goal for adequate pain relief, but the pain management approach relied heavily on as-needed (PRN) medications rather than scheduled dosing. The resident reported persistent, severe pain and expressed dissatisfaction with the effectiveness of acetaminophen, preferring oxycodone and wishing it was scheduled to avoid having to request it repeatedly. Observations during care activities, such as dressing changes, showed visible signs of pain, including grimacing and movement of the affected limb, with the resident rating pain as high as 8 out of 10 and frequently requesting pain medication. Review of the resident's medical record and medication administration records revealed frequent use of PRN oxycodone (67 times) and acetaminophen (8 times) over a short period, indicating ongoing, unresolved pain. Despite these frequent requests and high pain ratings documented in assessments and interviews, the facility did not adequately evaluate the effectiveness of the current pain management plan, failed to notify the provider about the frequent PRN use, and did not consider transitioning to scheduled pain medications. This lack of proactive pain management resulted in the resident experiencing ongoing pain and discomfort.