Failure to Provide Consistent and Appropriate Pain Management
Penalty
Summary
Facility staff failed to provide safe and appropriate pain management for a resident with multiple complex diagnoses, including a recent right hip fracture, Alzheimer's disease, and chronic pain conditions. The resident, who had severe cognitive impairment and was frequently experiencing pain, was noted to have pain levels as high as 6 out of 10 and exhibited behaviors such as calling out, moaning, and shouting for help. Despite these signs and the care plan's directive to notify the physician of unrelieved pain, documentation showed inconsistent pain assessments, lack of follow-up on pain interventions, and delays in adjusting pain management strategies. Progress notes and provider documentation revealed that the resident continued to experience pain even after receiving PRN narcotic pain medication, with staff sometimes only placing the resident on a rounding list for future provider evaluation rather than seeking immediate intervention. Orders for pain assessment were not consistently followed, as staff simply checked off pain monitoring without documenting pain scales or nonpharmacological interventions. There was also a lack of follow-up pain assessments after medication administration, and gaps in pain medication administration were noted despite ongoing reports of pain. Communication issues further contributed to the deficiency, as there were delays in clarifying and implementing new pain medication orders, confusion regarding medication allergies, and lack of timely documentation regarding hospice involvement and medication changes. Interviews with staff and providers indicated uncertainty about expectations for pain assessment frequency and appropriate escalation when pain was not controlled. Facility policy required regular pain reassessment and documentation, but these standards were not met, resulting in inadequate pain management for the resident.