Failure to Assess and Address Pain in Cognitively Impaired Resident with Increased Behaviors
Penalty
Summary
The facility failed to identify and respond appropriately to increased behaviors indicative of pain or distress in a cognitively impaired resident diagnosed with dementia. Staff interviews revealed that when a resident with dementia exhibited increased behaviors such as scratching, pinching, and yelling, staff would generally assess for basic needs like pain, positioning, incontinence, and perform a head-to-toe assessment. However, despite an observed increase in these behaviors, staff could not specify when the escalation began, and behavior monitoring records showed 15 incidents of such behaviors over a five-week period. A review of the resident's pain assessments indicated that only three assessments were completed during the same timeframe, with just one coinciding with a day when the resident exhibited behaviors. The care plan included interventions to identify stressors and assess pain, but there was no evidence in the medical record that pain was consistently assessed as a possible cause for the increased behaviors. Additionally, the Minimum Data Set (MDS) assessments documented an increase in physical behavioral symptoms but indicated that the resident did not receive or was not offered PRN pain medications. This demonstrates a lack of consistent assessment and response to potential pain or distress in the resident.