Failure to Address Resident's Breakthrough Pain and Provider Communication
Penalty
Summary
The facility failed to provide appropriate pain management for a resident with chronic pain and severe osteoarthritis. The resident was admitted with diagnoses including osteoarthritis of the hip and knee, and chronic pain. Physician documentation recommended continuing pain management with PRN acetaminophen, and the care plan included non-pharmaceutical interventions and reporting pain complaints to nursing staff. The resident's quarterly assessment indicated almost constant pain affecting sleep, daily activities, and therapy, with a self-reported pain level of seven out of ten. Medication orders for gabapentin and scheduled acetaminophen were administered as prescribed. Despite these interventions, the resident reported ongoing breakthrough pain and stated that requests for additional pain relief had not been addressed. The resident indicated that topical creams were ineffective and that a request for additional medication made weeks prior had not resulted in any action. Review of the clinical record revealed no documentation or communication with the provider regarding the resident's pain management needs or clarification of the PRN acetaminophen order. The Director of Nursing confirmed that there was no evidence the physician had been contacted for clarification, as would be expected.