Failure to Timely and Appropriately Address Resident Pain
Penalty
Summary
A deficiency was identified when a resident with a history of right hip dislocation, recent surgical intervention, and multiple comorbidities was not provided timely and appropriate pain management. The resident was admitted for post-surgical care and had an order for Tylenol 650 mg every four hours as needed for pain. Despite documented pain assessments indicating moderate to severe pain, the baseline care plan did not include interventions for pain related to the hip injury or surgery, and pain assessments were inconsistently documented. On several occasions, the resident reported moderate to severe pain, including two instances of severe pain, but did not receive Tylenol as ordered. During a medication pass, an LPN administered scheduled medications but did not include Tylenol, despite the resident expressing significant pain and rating it as an eight out of ten. The LPN incorrectly informed the resident that another medication (meloxicam) was for her pain and referenced a pain patch that was not actually ordered or applied. No documentation was found to indicate that non-pharmacological interventions were offered, that the resident declined Tylenol, or that the provider was notified of the increased pain. Further review of the medical record revealed no additional pain assessments or administration of Tylenol after the resident's reports of severe pain. The facility's medication administration policy required medications to be given timely and as prescribed, based on resident need and benefit. The failure to address the resident's pain in a timely and appropriate manner, as well as the lack of documentation and follow-up, led to the cited deficiency.