Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for two residents by not following professional standards of practice and the residents' person-centered care plans. One resident consistently reported chronic back pain due to arthritis, which was documented by a nurse practitioner, but there was no evidence that the pain was addressed or that the care plan goal of being free from discomfort was met. The resident's medical record confirmed an active diagnosis of pain, yet the pain management regimen was not adjusted in response to the resident's ongoing complaints until after surveyor intervention. Another resident with multiple medical diagnoses, including liver cell carcinoma, was admitted with frequent, moderate pain that affected sleep and was not relieved by non-pharmacologic interventions. Despite physician orders for pain assessments every shift and PRN morphine for comfort care, pain assessments were not consistently documented, and PRN medication was not administered as ordered. Staff failed to document ongoing pain assessments and did not provide pain medication as directed, even when the resident was observed to be uncomfortable and agitated. The Director of Nursing acknowledged these findings during the survey.