Failure to Provide Effective Pain Assessment and Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for three residents who required such services. For one resident with multiple diagnoses including fractures, chronic kidney disease, and a new wound, pain assessments documented pain ratings of 3 to 5 during weekly wound reviews, but no pain medication was administered despite physician orders for as-needed oxycodone-acetaminophen for moderate to severe pain. Another resident with pressure ulcers and intact cognition had no as-needed pain medication ordered, even though weekly wound reviews consistently documented pain ratings of 3 to 4. In both cases, there was no evidence that pain was managed according to the care plan interventions, which included administering pain medication as ordered and monitoring for effectiveness. A third resident with pressure ulcers and a history of chronic conditions had orders for both hydrocodone-acetaminophen for severe pain and acetaminophen for mild pain. Despite regular wound pain assessments showing pain ratings between 5 and 6, no as-needed pain medication was administered during the documented periods. Additionally, weekly wound pain assessments were not consistently completed as required by facility policy, and there was no follow-up after non-pharmacological interventions to determine if further treatment was needed. Interviews with facility staff, including the Assistant Director of Nursing and the wound nurse, confirmed that pain medications were not given prior to wound care treatments and that there was a lack of follow-up after interventions. The facility's policy required assessment, monitoring, treatment, and evaluation of pain to ensure effective management, but these steps were not consistently followed for the residents reviewed.