Failure to Address and Monitor Resident Pain Management
Penalty
Summary
The facility failed to address and monitor pain management for a resident with multiple chronic conditions, including rheumatoid arthritis, osteoarthritis, and bilateral lower extremity wounds. Despite the resident's report of almost constant pain, rated as a seven out of ten and affecting sleep, there was no documentation of pain management or administration of as-needed pain medications or topical treatments on the day of the pain assessment. The resident's care plan included interventions to anticipate and respond promptly to pain, evaluate the effectiveness of interventions, and document non-medication interventions prior to administering analgesics, but these were not followed. Interviews with staff revealed that routine pain monitoring and documentation were not conducted unless a PRN (as-needed) medication was administered. The medication administration record did not provide a place to document routine pain monitoring, and staff confirmed that pain effectiveness was only documented after PRN medication use. The facility's pain management policy required reassessment of pain management for effectiveness, but this was not implemented in practice. The Director of Nursing confirmed that no as-needed pain medication was given at the time of the pain assessment and that daily pain monitoring was not routinely performed.