Failure to Use Resident-Specific Pain Assessment Methods
Penalty
Summary
Facility staff failed to use a resident-specific pain assessment for a resident with diagnoses including bipolar disorder, dementia, and gait abnormalities. The facility's policy required staff to consider cognitive and other individual factors when assessing pain and to use a standardized pain assessment instrument appropriate to the resident's cognitive level. Despite this, staff consistently used only the 0-10 numerical pain scale to assess the resident's pain, even though she was often unable to verbalize her pain level or assign a number to her pain. Interviews with staff, including an LVN, the Director of Staff Development, the Director of Nursing, the Medical Director, and the MDS nurse, confirmed that the resident's pain was assessed by observing facial expressions and assigning a number on the 0-10 scale, regardless of the resident's ability to communicate her pain verbally. Staff acknowledged that this approach was not best practice and did not align with facility policy, which called for descriptive documentation and the use of alternative pain assessment tools such as FACES or Wong-Baker when residents could not use the numerical scale. The record review showed that the resident's care plan included instructions to monitor for non-verbal signs of pain and to report symptoms such as changes in breathing, mood, or facial expressions. However, staff did not consistently follow these instructions or reassess the effectiveness of pain interventions as required by policy. Facility leadership confirmed that staff did not adhere to the pain assessment policy and that immediate education was needed.