Failure to Adequately Assess and Manage New Onset Severe Shoulder Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate assessment and management for a resident’s new onset of severe left shoulder pain following a physical altercation with another resident. The resident, who had previously reported only mild, occasional pain that did not affect sleep and had intact cognition and no upper extremity ROM limitations per the MDS, began experiencing sharp, non-radiating left anterior shoulder pain rated 8–10/10 after the incident. The N Adv – Long Term Care Evaluation identified this as a new issue, with documented severe pain and facial expressions consistent with pain. Despite this, the resident reported that his existing pain medication regimen, which predated the incident, was not relieving the new shoulder pain, and he repeatedly requested an X-ray and hospital evaluation. Medication records showed that after the incident, the resident received PRN Acetaminophen-Codeine 300-30 mg and Tylenol Extra Strength 500 mg on multiple occasions, yet pain assessments documented ongoing moderate to severe pain levels (4–10/10) on numerous days. The resident consistently reported severe, unrelieved left shoulder pain, including during surveyor interviews, and described worsening pain with shoulder movement. Nursing documentation and interviews confirmed that the resident’s pain remained severe and that his left shoulder ROM was compromised, indicating a change in condition and ineffective pain control. However, there was no evidence that the pain management plan was promptly reassessed or modified in response to the resident’s persistent high pain scores and reports of inadequate relief. The facility’s own Pain Management Program policy required initiation of a pain assessment protocol whenever there is a change in condition requiring pain control or a change in the identification of pain, recognition of pain as the fifth vital sign, ongoing monitoring, and review and updating of care plans when pain management is ineffective. Interviews with the in-house NP and psychiatric NP emphasized that pain is subjective and must be taken seriously regardless of psychiatric status, and that uncontrolled pain can exacerbate psychological symptoms. Despite these expectations and the DON’s stated requirement that pain rated above 6/10 necessitates immediate action, the resident’s severe, ongoing pain after the new injury was not adequately assessed or managed in a timely manner, and the pain management plan was not effectively adjusted in accordance with facility policy until much later, when imaging ultimately revealed a left glenoid fracture.
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