Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
The facility failed to provide adequate and appropriate pain management for two of three residents reviewed for pain management. For one resident, the facility did not administer pain medication according to the physician's orders. The resident, who lacked capacity to make decisions, was given Tylenol for a pain level that was considered moderate, despite the physician's order specifying Tylenol only for mild pain. Both the LVN and the DON confirmed that the medication administered did not match the resident's pain level and that the physician should have been contacted to obtain an appropriate order for moderate pain. For another resident, the facility did not implement or document non-pharmacological pain interventions prior to administering PRN Tylenol for reported pain. The resident, who also lacked decision-making capacity, received Tylenol multiple times for pain levels ranging from moderate to severe. However, there was no documentation in the medical record that non-pharmacological interventions were attempted or their effectiveness assessed before giving the medication, as required by facility policy. Staff interviews confirmed that such interventions should have been tried and documented before administering PRN pain medication. The facility's policy on pain assessment and management requires that pain be managed according to the resident's clinical condition and treatment goals, with non-pharmacological interventions attempted and documented prior to pharmacological measures. In both cases, the facility did not follow its own policy, resulting in residents not receiving pain management services as ordered or documented.