Failure to Care Plan Turning/Repositioning and Pain Management for Nonverbal Resident
Penalty
Summary
Surveyors identified that the facility failed to develop a comprehensive and individualized care plan addressing turning/repositioning and pain management needs for a resident with multiple complex medical conditions. The resident was admitted with diagnoses including nontraumatic intracerebral hemorrhage, pneumonia, metabolic encephalopathy, muscle weakness, hemiplegia, severe protein malnutrition, tracheostomy, dysphagia, chronic pulmonary disease, and other serious conditions. A quarterly MDS assessment documented that the resident was nonverbal, had impaired cognition, was dependent on staff for rolling in bed and transfers, and had a stage 3 pressure injury. The resident was on a scheduled pain regimen and received PRN pain medications, and a pain assessment showed the resident was unable to answer questions about pain presence, intensity, impact on sleep, therapy participation, or daily activities, and could not use a verbal descriptor scale. Record review showed physician orders for scheduled and PRN acetaminophen and PRN tramadol for pain, but the care plan, dated and revised during the stay, only addressed impaired skin integrity with general interventions such as assisting with hygiene and keeping skin clean and dry. There were no care plan interventions for turning and repositioning to offload pressure, no physician orders for turning and repositioning, and no care plan developed for pain medications, measurable pain-related goals, or pain interventions, including individualized pain assessment strategies for a nonverbal resident. An RN interview confirmed the resident had a wound on the buttocks and that staff were expected to turn and reposition the resident at least every two hours and assess pain through physical signs such as facial tension. The DON confirmed that physician orders did not include turning and repositioning every two hours and that the facility had not implemented a care plan for turning/repositioning or for pain, despite facility policies requiring care plans for pressure ulcer prevention and pain assessment and management.
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