Failure to Provide Timely and Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for two residents who required such services, resulting in missed and delayed administration of scheduled pain medications, lack of pain assessments, and failure to offer alternative or non-pharmacological interventions as ordered. One resident, a female with diagnoses including fibromyalgia, chronic pain, and intact cognition, did not receive her scheduled doses of Oxycodone and Gabapentin on multiple occasions. Documentation showed that her pain assessments were not completed as required, and when doses were missed, the physician was not notified. Additionally, alternative PRN pain medications and non-pharmacological interventions, such as Tylenol and hot packs, were not offered per facility policy. The resident reported increased pain and agitation due to these lapses, and staff interviews confirmed confusion and lack of follow-through regarding medication administration and pain management responsibilities. Another resident, a male with severe cognitive impairment, dementia, and chronic pain, did not receive consistent pain assessments or PRN pain medications despite displaying nonverbal signs of pain such as grimacing, moaning, and pushing staff away during care. Although he was prescribed scheduled and PRN opioid medications, records indicated that PRN medications were not administered when he exhibited clear signs of discomfort during ADL care and wound treatments. Staff interviews revealed that pain assessments were not consistently documented, and PRN medications were not given prior to care activities known to cause pain, despite orders and care plan interventions specifying the need for such measures. The facility's failure to follow its own pain management policy, including timely administration of medications, documentation of pain assessments, and offering of alternative interventions, led to residents experiencing unmanaged pain and distress. Staff interviews and documentation review highlighted lapses in communication, inadequate handoff between shifts, and lack of adherence to professional standards of practice and individualized care plans. These deficiencies were identified by surveyors and resulted in an Immediate Jeopardy situation, though the report does not detail the corrective actions taken after the incident.