Failure to Provide Adequate Pain Management
Penalty
Summary
A resident with multiple complex medical conditions, including quadriplegia, polyneuropathy, a history of a displaced bimalleolar fracture, hypertension, type 2 diabetes, and COPD, was admitted to the facility and identified as being at risk for pain. The resident's care plan included interventions such as administering medication as ordered, monitoring for pain every shift, and notifying the physician as needed. Physician orders were in place for acetaminophen as needed for pain and a daily aspirin, though the DON later clarified that the aspirin was not intended for pain management. Despite these orders, documentation showed that the resident reported significant pain levels of 7 and 8 out of 10 on two consecutive days, but did not receive any pain medication on those occasions. Further review of the medical record and interviews confirmed that the resident had not received any pain medication since admission, and there was no documentation of non-pharmacological pain interventions being offered or implemented. The DON acknowledged these findings and confirmed the lack of pain management provided, despite the resident's ongoing pain and an upcoming appointment at a pain clinic. The facility's pain assessment and management policy required staff to identify pain and develop interventions to meet the resident's goals, but these steps were not followed in this case.