Failure to Provide Timely Pain Management for Resident with Acute Pain
Penalty
Summary
The facility failed to provide appropriate pain management for a resident who was experiencing acute pain. According to the facility's pain management policy, a pain evaluation should occur with any new onset of pain, and the physician should be notified of new or significantly increased pain. The resident, who was cognitively intact and required assistance with daily care, had a physician order for scheduled Tylenol. On one occasion, the resident was found to have a deep vein thrombosis (DVT) in the left lower extremity and was started on anticoagulant therapy. Despite this, nursing documentation indicated that the resident continued to experience significant pain that was not relieved by the scheduled Tylenol, including crying out in pain during care and expressing distress about her pain. A note was placed in the physician's communication book requesting comfort care, stronger pain medication, or hospice, but there was no documented evidence that the physician was contacted at that time for additional interventions or treatment to relieve the resident's pain. The Director of Nursing confirmed that the resident's acute pain was not controlled as it should have been. This lack of timely physician notification and intervention for uncontrolled pain constituted a failure to follow the facility's pain management policy and provide adequate nursing services.