Failure to Provide Adequate Pain Management and Transfer Alternatives
Penalty
Summary
A resident with a history of chronic pain, including diagnoses such as Type 2 Diabetes Mellitus, hemiplegia, osteoarthritis, and rotator cuff pathology, experienced ongoing pain exacerbated by the use of an EZ stand lift for transfers. Despite being cognitively intact and repeatedly expressing that the EZ stand caused significant shoulder pain, the facility did not adequately address her pain needs or seek alternative transfer methods. The resident reported crying multiple times daily during transfers and requested re-evaluation for different transfer options, but received no response from therapy or facility leadership. Facility staff, including CNAs and the social worker, were aware of the resident's pain during transfers, with multiple staff members acknowledging that the EZ stand caused her distress and that she cried during each use. The care plan included interventions to evaluate pain management and check comfort levels, but there was no evidence that the plan was updated or that new interventions were implemented in response to the resident's ongoing complaints. The Director of Nursing and other staff confirmed knowledge of the pain but did not initiate increased pain assessments, care plan revisions, or interdisciplinary team meetings as outlined in facility policy. Medication records showed frequent use of both scheduled and PRN pain medications, and physician notes documented persistent pain despite these interventions. The facility failed to reassess the resident's pain management plan or develop and implement new approaches to transferring, and did not ensure that front line staff were informed of the resident's preferences regarding transfers. As a result, the resident continued to experience daily pain associated with the use of the EZ stand, and her care plan was not revised to address her ongoing needs.