Failure to Provide and Document Appropriate Pain Management
Penalty
Summary
A resident with severe cognitive impairment, Alzheimer's disease, COPD, and osteoporosis was admitted to the facility and later reported right shoulder pain, which was confirmed by x-ray to be a non-displaced humerus fracture. The resident had a history of pathological fractures and required maximum assistance with all activities of daily living. Documentation showed that the resident complained of significant pain, rated as high as 8 out of 10, with noted tenderness and limited range of motion. Despite these findings, there was no documentation that pain medication or any intervention was administered at the time of the initial complaint or during subsequent pain assessments. Further review of the Medication Administration Record (MAR) and nursing progress notes revealed no evidence that pain medication was given, even though pain was monitored and the resident continued to report discomfort. Interviews with facility staff, including the ADON and an LPN, confirmed that pain management interventions were not documented or possibly not provided, and that the physician was not notified as required. The facility's policy required staff to assess, intervene, and document pain management, but these steps were not followed, resulting in a failure to manage the resident's pain according to professional standards of practice.