Failure to Involve Resident in Pain Management Care Planning and Education
Penalty
Summary
A deficiency occurred when a resident admitted for short-term rehabilitation following a right knee replacement was not properly informed or involved in her pain management care planning. The resident was initially prescribed Percocet as needed every six hours for moderate to severe pain, but the order was changed to a routine schedule of every four hours without documentation of the reason for the change or evidence that the resident was notified or involved in the decision. The resident reported that she was not informed about the risks, benefits, or potential side effects of routine opioid use, including the risk of withdrawal symptoms, nor was she offered non-pharmacological alternatives for pain management. During her stay, the resident experienced withdrawal symptoms after requesting a decrease in the opioid medication's dose and frequency. She reported symptoms such as chills, hot flashes, runny nose, pain, anxiety, nausea, vomiting, tremors, watery eyes, decreased appetite, and difficulty sleeping. The resident stated that she had not been told why the medication was to be taken every four hours and was not involved in the decision-making process regarding her pain management plan. Nursing staff confirmed that they had not discussed the plan to administer opioids routinely or explained the associated risks and benefits to the resident. Interviews with facility leadership, including the DON and Regional Nurse Consultant, revealed that there was no specific policy for resident rights beyond following federal guidelines. They acknowledged that the resident should have been consulted and educated about her pain management options, including the risks of opioid use and the potential for withdrawal symptoms. Documentation in the clinical record was lacking regarding the rationale for medication changes and resident notification.