Failure to Provide Timely and Effective Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for two residents who required such services, as evidenced by multiple instances of unaddressed or ineffectively managed pain. For one resident with a history of palliative care, dementia, traumatic brain injury, and chronic pain conditions, there were documented complaints of severe pain in the right shoulder and neck. Despite administration of prescribed pain medications such as Oxycodone and Acetaminophen, the pain was reported as ineffective on several occasions. There was no documentation that the provider was notified of the ineffective pain relief, nor evidence of follow-up interventions or reassessment as required by the resident's care plan and facility policy. Interviews with nursing staff and the DON confirmed that provider notification and documentation were expected but not completed in these instances. Another resident with hemiplegia, aphasia, and a history of cerebral infarction experienced right shoulder pain following a dislocation, which was suspected to have occurred during a transfer. The resident received pain medications and non-pharmacological interventions, but these were documented as ineffective on more than one occasion. There was no evidence that additional pain management strategies were implemented or that the provider was promptly notified of the ongoing uncontrolled pain. Nursing notes indicated that the resident continued to experience pain, and staff interviews revealed uncertainty about the origin of the injury and incomplete incident reporting. The DON acknowledged that an abuse investigation was initiated but not completed, and there was a lack of detailed documentation regarding staff interviews and the cause of the injury. Both cases demonstrate a failure to follow professional standards of practice and the residents' person-centered care plans regarding pain management. The facility did not ensure timely notification of providers when pain interventions were ineffective, nor did it consistently document follow-up actions or reassessments. These deficiencies resulted in residents experiencing uncontrolled pain without appropriate escalation or modification of their pain management plans.