Failure to Ensure Safe and Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for two residents, resulting in deficiencies related to the administration and assessment of pain medication. For one resident with chronic pain and multiple comorbidities, staff did not consistently assess pain levels using a numerical scale as required by physician orders, nor did they document the effectiveness of pain interventions. Observations revealed the resident experiencing significant pain, including crying out when the affected area was touched, and reporting high pain scores. Despite physician orders specifying the use of Percocet for moderate to severe pain, the resident was sometimes given Tylenol instead, and non-pharmacological interventions were not documented as attempted prior to medication administration. Additionally, there were instances where pain medication was not administered as ordered due to staff not checking available medication supplies or following up with the pharmacy appropriately. The same resident's care plan included interventions such as administering pain medications as ordered, monitoring for effectiveness, and offering non-pharmacological interventions, but these were not consistently implemented. Documentation in the Medication Administration Record (MAR) often lacked pain scale ratings, and follow-up assessments of pain relief were not always completed. Staff interviews confirmed that pain was not always assessed or managed according to the care plan and physician orders, and that system limitations in the electronic record may have contributed to incomplete documentation. For another resident with multiple sclerosis and recent lower extremity fractures, the facility did not ensure pain assessments were completed every shift as ordered by the physician. Review of records showed missed pain assessments on several night shifts, particularly after a fall and subsequent diagnosis of multiple metatarsal fractures. The night shift Certified Medical Assistant (CMA) was not qualified to perform pain assessments, and the supervising LPN did not document the required assessments, despite being responsible for this task. These failures resulted in inadequate monitoring and documentation of pain for residents with significant pain management needs.