Failure to Implement Non-Pharmacological Pain Interventions and Document Acceptable Pain Level
Penalty
Summary
The facility failed to implement the care plan for a resident by not carrying out non-pharmacological interventions for pain management and by not identifying or documenting an acceptable pain level for the resident. Record review showed that although the care plan included monitoring for pain, attempting non-pharmacological interventions, and documenting their effectiveness, these interventions were not consistently attempted or documented when the resident reported pain. Discrepancies were found in the Medication Administration Record (MAR) and progress notes, with some entries indicating pain was present but no non-pharmacological interventions were tried, while other entries showed interventions were attempted or pain levels differed for the same shift. Additionally, the resident's care plan included a goal for pain to be managed at an acceptable level, but no such level was documented. Further review of the MAR and eMAR progress notes indicated that as-needed (PRN) pain medications were administered on multiple occasions without prior attempts at non-pharmacological interventions, as required by the care plan. The Director of Nursing (DON) confirmed during an interview that non-pharmacological interventions had not been attempted and that an acceptable pain level had not been documented for the resident. This deficiency was identified for one resident out of thirty care plans reviewed during the survey process.