Failure to Manage Pain for Residents with Cognitive Impairment and After Injury
Penalty
Summary
The facility failed to adequately manage pain for two residents with cognitive impairments. For one resident with end-stage dementia and chronic pain, the care plan required staff to use the PAINAD scale for pain assessment due to the resident's inability to verbally express pain. Despite multiple documented instances where the resident was assessed as experiencing pain at varying levels, including a high pain score of 8, there was no evidence in the medical record that staff took action to manage the resident's pain on those occasions. The director of nursing confirmed the absence of documentation regarding pain management interventions following these assessments. In another case, a resident who experienced a fall and subsequently exhibited signs of pain, such as limping and guarding, was not provided with pain management prior to being transferred to the hospital. The facility's investigation and review of the resident's records did not show any documentation of pain management before the hospital transfer, despite the resident later being diagnosed with a right pelvic fracture. The director of nursing acknowledged that pain management was expected but not documented or provided before the resident's transfer.