Failure to Provide Timely and Effective Pain Management
Penalty
Summary
A deficiency was identified when the facility failed to provide safe and appropriate pain management for a resident with multiple chronic pain-related diagnoses, including cerebrovascular disease, chronic gout, contractures, and rheumatoid arthritis. The resident's care plan required staff to notify the physician if pain medications or non-pharmacological interventions were ineffective, and to maintain the resident's comfort without signs of unrelieved pain. However, medical records showed that after the resident reported pain levels of 6 and 7 out of 10 and stated that the prescribed pain medication was ineffective, no alternative interventions or additional medications were offered for several hours. Documentation did not reflect any follow-up actions or communication with the physician as required by the care plan and facility policy. Despite the resident later expressing satisfaction with her pain management and not recalling any instances where staff failed to assist her, the facility's records indicated a lack of timely and appropriate response when pain was not controlled by the current regimen. The administrator was unaware of why staff did not document interventions when the medication was ineffective. The facility's policy required staff to notify the practitioner if pain was not controlled, but this was not documented or carried out in the instances reviewed.