Failure to Perform and Document Physician-Ordered Pain Monitoring
Penalty
Summary
Facility staff failed to ensure that a resident received treatment and care in accordance with professional standards of practice, specifically by not performing physician-ordered daily pain monitoring. The resident, an elderly male with a complex medical history including joint replacement surgery, diabetes, hypertension, dementia, and a recent hip fracture, had a physician order for pain monitoring every shift using a verbal/nonverbal 0-10 scale. Documentation and interviews revealed that pain assessments were not completed or recorded for two consecutive days, despite the ongoing order and the facility's policy requiring pain assessment every shift. Record reviews showed that the resident's Medication Administration Record (MAR) did not include documented pain levels, and there were no progress notes, assessments, or vitals indicating pain monitoring for the specified dates. Video evidence further demonstrated that a CNA transferred the resident without a second person assist, did not use a gait belt, and did not assess or report the resident's pain using the required scale. Multiple staff interviews confirmed inconsistent understanding and execution of pain assessment protocols, with some staff unable to recall if pain assessments were completed or documented as required. The facility's pain screening and assessment policy mandates that every shift, a pain score must be documented for each resident, and that comprehensive pain assessments are to be performed for residents with a positive pain score. The policy also requires that pain intensity be included as the fifth vital sign during routine vitals. Despite these requirements, the resident's pain monitoring was not performed or documented as ordered, constituting a failure to provide care in accordance with professional standards and the facility's own policies.