Failure to Notify Physician of Ineffective Pain Management
Penalty
Summary
A deficiency was identified when the facility failed to immediately consult with a resident's physician following significant complaints of uncontrolled pain. The resident, who had a complex medical history including palliative care, dementia, traumatic brain injury, and chronic pain conditions, reported severe pain in the right shoulder and neck, rating it as 8 out of 10. Despite having orders for Oxycodone and Acetaminophen as needed for pain, documentation showed that pain medications were administered on multiple occasions with noted ineffectiveness, yet there was no evidence that the physician was notified of the ineffective pain management as required by the resident's care plan. Interviews with nursing staff and the Director of Nursing confirmed that the facility's protocol required physician notification when pain interventions were unsuccessful, and that such notifications should be documented in the medical record. However, review of the records revealed no documentation of provider notification or additional pain management interventions following reports of ineffective pain relief. The hospice nurse was only notified of the resident's uncontrolled pain after repeated ineffective pain management, leading to a change in the pain management plan.