Failure to Provide Timely and Appropriate Pain Management
Penalty
Summary
A deficiency was identified when a resident with a history of atherosclerotic heart disease, arthritis, and a childhood neck injury reported significant pain to facility staff. The resident expressed that he was experiencing severe neck and back pain, requested to go to the hospital, and stated that his current pain management regimen of two Tylenol was ineffective. Despite these complaints, the resident was not provided with any pain medication, alternative pain relievers, or nonpharmaceutical pain interventions at the time of his request. Staff responses included relaying the complaint to a nurse, who indicated she would contact the Medical Director, and instructing the resident to rest, but no immediate pain relief measures were implemented. Review of the resident's care plan revealed it was focused on headache pain and included interventions such as medication and rest, anticipating pain relief needs, and documenting pain history and management. The care plan also noted the resident's preference for Tylenol, but did not address his arthritis or neck pain specifically. The resident's recent pain assessment documented frequent pain, with significant interference in sleep and activities, and a high pain score. Orders for acetaminophen and topical analgesics were present, but there was no documentation that these were offered or administered during the pain episode in question, nor was there documentation of refusal. Interviews with the resident confirmed that he had not received any pain relief or intervention following his complaints. The DON stated that the Medical Director was contacted, but the response was delayed by several hours, and there was no evidence of alternative pain management strategies being discussed or implemented. Documentation was lacking regarding pain assessments, interventions offered, and resident refusals, contributing to the failure to provide appropriate pain management as required.