Failure to Reassess and Effectively Manage Ongoing Pain
Penalty
Summary
The facility failed to provide effective pain management for a resident admitted with a right humerus fracture, head injury, and iron deficiency anemia. At admission, the care conference established goals to get the resident’s pain under control and to work with therapy, and a pain evaluation set the resident’s acceptable pain level at 4/10. Medication orders included scheduled Tylenol Extra Strength 500 mg, two tablets three times daily, and PRN oxycodone 5 mg every eight hours for severe pain. The MAR showed 17 administrations of oxycodone over the review period, with documented pain scores ranging from 6/10 to 10/10, all above the resident’s stated acceptable pain level. Physical therapy notes during the same period documented ongoing shoulder pain that created barriers to participation, with one entry describing the resident as very upset with 10/10 pain and emotional about wanting to improve mobility to return home. Another therapy note recorded increased pain while the resident was lying in bed and a request to nursing to administer pain medication. Observations found the resident guarding her right shoulder and reporting she was always in pain and could not recall a time since admission when her pain had been under control, and later stating she was in pain all the time during a medication pass. The DON stated she believed the resident’s pain was well managed based on PRN effectiveness, but upon review of the record did not identify documentation of reassessment or evaluation of the overall pain management plan despite repeated reports of pain levels above the resident’s acceptable goal.
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