Failure to Ensure Timely and Documented Pain Management for Residents
Penalty
Summary
The facility failed to provide safe and appropriate pain management for two residents with chronic pain and complex medical histories. For one resident with chronic pain, polyosteoarthritis, COPD, chronic kidney disease, and heart failure, there was no care plan in place to address her pain. Although physician orders specified the use of tramadol as needed, with requirements for pain assessment before and after administration, documentation of pain scale results, vital signs, and non-pharmacological interventions, these were not completed. Medication administration records showed tramadol was given on two occasions, but the corresponding treatment records and progress notes lacked required documentation, including vital signs and non-pharmacological interventions. The effect of the medication was also not documented in one instance. For another resident with diagnoses including cancer, right femur fracture, peripheral vascular disease, inguinal hernia, and spinal stenosis, the care plan included goals and interventions for pain management, such as anticipating pain needs and encouraging non-pharmacological methods. However, the resident reported significant delays in receiving as-needed pain medication, particularly at night, with one instance where he waited several hours after requesting medication. Physician orders required pain assessments, documentation of pain scale, vital signs, and non-pharmacological interventions before and after PRN medication administration, but these were not documented in the treatment records or progress notes for multiple administrations. Interviews with the DON confirmed that vital signs were supposed to be obtained and documented when residents complained of pain, but this was not consistently done. The facility's pain management policy required timely interventions and documentation of both pharmacological and non-pharmacological measures, but the records reviewed did not reflect compliance with these requirements for the residents involved.