Failure to Provide Comprehensive Pain Management and Assessment
Penalty
Summary
The facility failed to provide safe and appropriate pain management services consistent with professional standards of practice for two out of five residents reviewed. For one resident with a history of fibromyalgia and chronic pain, documentation showed frequent and severe pain, with pain scores ranging from 5 to 10 prior to administration of as-needed opioid analgesics. Despite this, there was no comprehensive pain care plan or thorough pain assessment in the resident's records, and the care plan lacked any interventions for pain. The resident reported that pain medication was only effective for a short period and that non-pharmacological interventions were never offered, even though the resident expressed willingness to try them. Medication administration records indicated repeated use of as-needed pain medication, with several instances where pain was not relieved and no follow-up actions were documented. Another resident with diagnoses including unspecified pain, low back pain, and dysuria was also not provided with a comprehensive pain management plan. Although the resident received scheduled pain medications and reported that these were effective, the care plan only referenced pain management under a self-care deficit section and did not include specific problems or goals related to pain. Non-pharmacological interventions were minimally documented, and the care plan failed to mention all prescribed pain medications. Pain assessments were incomplete, lacking details such as pain location, acceptable pain levels, and effectiveness of interventions. Medication administration records did not consistently document pain levels using the required scale. Interviews with the Director of Nursing confirmed the absence of comprehensive pain care plans and assessments for both residents. When asked about the adequacy of the care plans and assessments, the DON did not provide an answer. No additional information or justification for the lack of comprehensive pain management documentation was provided by facility leadership when requested by surveyors.