Failure to Provide and Document Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with severe cognitive impairment and a history of type 2 diabetes and dementia. The resident developed swelling and bruising on her right wrist, which was reported to nursing staff and the nurse practitioner (NP). Orders were given for a stat x-ray and ice pack application, but the x-ray was not completed within the expected four-hour window, and the imaging performed was of the forearm rather than the wrist. Despite ongoing swelling and bruising, the resident remained in the facility without timely escalation or reassessment, and the stat x-ray order was not properly followed up as required by facility policy. Throughout the incident, pain management was inconsistent and not documented according to professional standards or the facility's own pain management policy. The resident was administered Tylenol routinely, but there was no documentation of pain assessments or follow-up on the effectiveness of pain medication in the treatment administration record (TAR). Staff interviews revealed that pain assessments were not consistently performed or recorded, especially for residents unable to verbalize pain, and that documentation of pain and medication effectiveness was lacking. The facility's policy required monitoring and recording of pain medication effectiveness, but this was not done for the resident in question. The deficiency was further compounded by communication issues among staff, delays in obtaining appropriate diagnostic imaging, and a lack of timely escalation to higher levels of care when the stat x-ray was not completed. The resident was eventually sent to the hospital at the request of her responsible party, where a wrist fracture was diagnosed. The failure to follow the facility's pain management policy and to document pain assessments and medication effectiveness placed the resident at risk of uncontrolled pain.