Failure to Assess and Manage Resident Pain as Reported by Family
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with multiple complex medical conditions, including dementia with severe cognitive impairment, chronic pain, congestive heart failure, COPD, and osteoporosis. The resident's care plan included interventions for pain management and skin breakdown prevention, and physician orders were in place for scheduled and PRN pain medications. Despite these measures, there was a failure to assess the resident's pain level when the family reported the resident was in pain and requested pain medication. On the day in question, the resident's family reported that the resident was crying in pain and requested pain medication. The nurse informed the family that the resident had just received medication and could not receive more until a later time. However, upon review, it was found that the resident had not actually received pain medication at the time stated by the nurse. There was no documented pain assessment during the period when the family reported the resident was in pain, and the nurse was unable to specify the resident's pain level at that time. The facility's policy required pain assessment whenever pain was reported or medication was administered, but this was not followed. Interviews with staff confirmed that the expectation was to assess pain whenever a resident complained of pain, and that pain assessments should be documented with each administration of pain medication. The lack of assessment and documentation meant that the resident's pain was not properly evaluated or managed according to professional standards and the facility's own protocols.