Failure to Implement and Document Non-Pharmacological Pain Interventions
Penalty
Summary
A deficiency was identified regarding the management of pain for a resident who experienced frequent and significant pain affecting sleep and activities of daily living. The resident reported ongoing pain, rating it as high as eight out of ten, and expressed that the pain was not controlled. The care plan for the resident included monitoring for pain, attempting non-pharmacological interventions, and administering pain medication as ordered, with documentation of effectiveness. However, review of the Medication Administration Record (MAR) and care plan revealed inconsistencies and discrepancies in pain assessment documentation, as well as a lack of non-pharmacological interventions being attempted or documented when pain was reported. Multiple entries in the MAR showed that when the resident reported pain, non-pharmacological interventions were either not attempted or not documented, despite orders requiring such interventions before administering as-needed (PRN) pain medication. There were also discrepancies between different entries for the same shift regarding the resident's reported pain level and whether interventions were attempted. The administration of PRN pain medications was documented on several occasions without evidence that non-pharmacological measures were tried first, as required by the resident's care plan and physician orders. Additionally, the care plan and pain assessments did not identify or document an acceptable pain level for the resident, despite a goal stating that wound-related pain should be managed at an acceptable level for the patient. The Director of Nursing confirmed that no acceptable pain level was documented and that non-pharmacological interventions had not been attempted. These findings demonstrate a failure to implement and document appropriate pain management interventions and to establish an acceptable pain level for the resident.