Failure to Provide and Document Safe, Appropriate Pain Management
Penalty
Summary
Surveyors identified deficiencies in the facility's pain management practices for multiple residents with chronic pain and complex medical histories. For one resident with diagnoses including bipolar disorder, emphysema, spinal stenosis, and chronic pain, the medical record showed that as-needed (PRN) pain medication was administered even when the resident reported a pain level of zero. Documentation was incomplete, with missing descriptions of pain and lack of evidence that nonpharmacological interventions were attempted prior to medication administration, as required by the care plan and facility policy. The Director of Nursing confirmed that PRN pain medications should not be given for a pain level of zero and that documentation of nonpharmacological interventions and pain descriptions was expected with each administration. Another resident with chronic pain syndrome, diabetes with polyneuropathy, and other comorbidities was receiving scheduled and PRN pain medications. The care plan required evaluation of the effectiveness of pain interventions and documentation of resident satisfaction and impact on function. However, the Medication Administration Record showed that while pain levels were recorded at the time of medication administration, there was no follow-up documentation evaluating the effectiveness of the pain medication. Interviews with staff confirmed that effectiveness was not routinely assessed after administration, and there was no established pain goal for the resident. Facility policy required documentation of the reasons for administration and the effectiveness of pain medications in the medical record, as well as monitoring and physician notification as needed. The survey found that these requirements were not consistently met for the residents reviewed, resulting in a failure to provide safe, appropriate, and well-documented pain management services.