Failure to Assess, Monitor, and Treat Pain According to Standards
Penalty
Summary
The facility failed to assess, monitor, and treat pain in accordance with professional standards for three residents, resulting in actual harm. For one resident, nursing staff documented multiple instances of moderate to severe pain over several months but did not provide either non-pharmacological or pharmacological interventions as ordered by the physician. The nurse also failed to assess the pain for location or duration and did not notify the physician of the resident's increased pain, despite clear orders to do so when pain was not controlled or was new in onset. Another resident experienced an increase in pain upon movement and transfers. Although pain medication was administered and later increased, staff did not assess the underlying cause of the pain, which was subsequently found to be due to two fractures. In a separate case, a resident reported numbness and tingling at an amputation site, which was communicated to the physician. The physician indicated the issue would be addressed the following day, but there was no documentation that the resident was evaluated or that treatment was prescribed, and the resident continued to experience symptoms. Additionally, for a resident who was prescribed a new pain medication, staff failed to notify the physician when the ordered medication was unavailable and did not obtain an alternative order, despite the availability of a substitute medication. This resulted in the resident not receiving pain relief in the hours prior to death. These failures were confirmed through record review, staff interviews, and resident interviews, and affected three of eight sampled residents reviewed for pain management.