Failure to Provide Effective Pain Management
Penalty
Summary
The facility failed to provide effective pain management for residents experiencing significant pain, as evidenced by the care of two residents with complex medical conditions. One resident, who had a history of brain cancer, brain abscess, recent brain surgery, back pain, bilateral leg pain from blood clots, and generalized deconditioning, was not effectively managed for pain. Despite physician orders specifying the use of over-the-counter pain medication for mild pain and narcotic pain relievers for severe pain, the resident continued to experience unrelieved pain, particularly in the legs, and expressed distress. The care plan directed staff to notify the physician if interventions were unsuccessful, but the resident's representative reported ongoing inadequate pain control. Another resident with a bone infection and back pain had a care plan and physician orders that required staff to assess pain, attempt non-pharmacological interventions before administering pain medication, and provide specific dosages based on pain severity. However, documentation showed that the resident received a lower dose of pain medication than ordered for high pain levels, and non-pharmacological interventions were not provided as required. The resident reported not receiving the correct medication dose for several days and was offered an ineffective over-the-counter medication instead, leading to frustration and continued pain. Interviews with staff confirmed that pain management protocols were not consistently followed. Staff acknowledged that the pharmacy should have been contacted to obtain the correct medication and that the provider should have been notified to ensure orders were followed. The facility's policy required collaboration with healthcare professionals and the use of both pharmacological and non-pharmacological interventions, but these standards were not met, resulting in untreated pain and discomfort for the residents involved.