Failure to Implement and Document Pain Assessments per Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple medical conditions, including dementia, cognitive communication deficit, type 2 diabetes, hypertension, heart failure, muscle weakness, peripheral vascular disease, and a history of falls. The resident's care plan, initiated in early September, specified that pain assessments should be conducted and documented every shift due to the presence of acute/chronic pain related to peripheral vascular disease. However, record review showed that pain assessments were not consistently performed or documented at the start of each shift as required by the care plan. Interviews with facility staff, including the DON Trainee and the Administrator, confirmed that the care plan's directives were not followed, and that nursing staff were responsible for completing and documenting pain assessments. Documentation reviewed indicated irregular pain level checks, with several shifts lacking any recorded assessment. The facility's own care planning policy requires the interdisciplinary team to develop and implement a comprehensive care plan, with all interventions communicated and carried out as specified, but this was not adhered to in the case of the resident in question.