Failure to Provide Timely Pain Management and Documentation
Penalty
Summary
A deficiency was identified when a resident experienced severe, unrelieved pain for an extended period without timely assessment or intervention. The resident, who was alert and oriented with a BIMS score of 15/15, began experiencing severe bilateral leg pain, rated at 10/10, starting in the evening and continuing into the following morning. Despite the resident's ongoing complaints and visible distress, there was no documented pain assessment or administration of pain medication during this time. Progress notes later indicated that pain medications and a lidocaine patch were ordered and reportedly administered, but the Medication Administration Record (MAR) did not reflect any such administration on the date in question. Staff interviews revealed that pain assessments are expected to be conducted every shift, and the DON confirmed that pain should be managed immediately with all interventions documented in the MAR. However, there was a five-hour gap between the initial documentation of severe pain and the resident's transfer to the hospital, during which no pain assessment or medication administration was documented. This failure to provide timely pain management and proper documentation constituted the identified deficiency.