Failure to Implement and Revise Pain Management Interventions
Penalty
Summary
A deficiency occurred when the facility failed to implement, monitor, and revise pain management interventions for a resident with chronic pain and a history of spinal surgeries. The resident was admitted with a diagnosis of chronic back pain and had been on long-term opioid therapy, specifically Dilaudid, prior to admission. Upon admission, the resident was prescribed Dilaudid 2 mg five times daily for five days, along with PRN acetaminophen. The facility's policy required ongoing assessment and revision of pain management based on the resident's needs and professional standards of practice. Throughout the resident's stay, documentation revealed inconsistent and inadequate assessment and management of pain. There were multiple instances where the resident reported severe pain (ratings of 7 to 10 on a 0-10 scale), yet there was no evidence that the pain management regimen was revised or that additional pharmacological or non-pharmacological interventions were implemented beyond rest. Documentation often lacked details regarding the site of pain, the effectiveness of interventions, and follow-up assessments. After the scheduled Dilaudid order ended, the resident experienced high pain levels, and the facility did not have a plan for tapering or continuing opioid therapy, nor did they ensure timely communication with the medical provider to obtain a new order. The resident ultimately went without Dilaudid for over 24 hours, leading to severe, uncontrolled pain. The family removed the resident from the facility against medical advice due to the lack of adequate pain control. Interviews with staff confirmed that there was no plan in place for managing the resident's pain after the Dilaudid order expired, and that follow-up with the provider was not completed in a timely manner. The DON confirmed that the resident's pain was not under control at the time of discharge.