Failure to Complete Shift Pain Assessments for Cognitively Impaired Resident
Penalty
Summary
The facility failed to complete pain assessments every shift for a resident with multiple chronic pain-related diagnoses, including vascular dementia, fibromyalgia, and chronic pain syndrome. The resident was severely cognitively impaired and unable to consistently verbalize pain, requiring staff to use both verbal and non-verbal pain assessment tools. Documentation showed that the care plan and hospice plan of care required regular pain monitoring and assessment using appropriate scales. However, record review revealed that pain assessments were not consistently completed every shift as required. Observations and interviews indicated that the resident experienced ongoing pain, including pain related to a right heel deep tissue injury and generalized discomfort. Staff interviews confirmed that pain assessments were supposed to occur every shift, but this was not consistently documented or ordered. The lack of regular pain assessments placed the resident at risk for unmet care needs and diminished quality of life, as noted in the report.