Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with a history of pain, osteoarthritis, and multiple sclerosis. Facility policy required comprehensive pain assessments upon admission, quarterly, with significant changes, and with new or worsening pain, as well as documentation of pain management interventions consistent with the resident's goals. However, the resident did not receive a comprehensive pain assessment for over eight months, despite ongoing pain management issues. When an assessment was completed, the resident reported almost constant pain and set a pain goal, but there was no evidence that pain management interventions were consistently aligned with this goal. Medication administration records revealed that the resident received as-needed (prn) Tylenol and oxycodone for varying pain levels, including instances where both medications were given simultaneously on multiple occasions. There were also several doses where the effectiveness of the medication was either unknown or documented as ineffective. Additionally, prn medications were administered without clear parameters, and some doses were given for pain levels of zero or for fever when the resident did not have an elevated temperature. Staff interviews confirmed that prn pain medications lacked appropriate parameters and that the two medications should not have been administered together.