F0697

E

Failure to Assess, Communicate, and Manage a Resident’s Pain

Downey, California Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to effectively assess, reassess, and manage pain for a resident with chronic conditions including osteoarthritis, schizophrenia, anxiety, chondrocostal junction syndrome, and gait abnormalities. The resident’s MDS showed moderately impaired cognition and a need for assistance with ADLs. The care plan for arthritis directed staff to monitor, document, and report joint pain and related symptoms, and the chronic pain care plan instructed staff to anticipate pain needs and respond immediately to any complaint of pain. After a fall on 10/9/2025 that led to hospital evaluation, the resident reported worsening popping sensations and pain in the knee, which she stated she had repeatedly reported to nursing and rehabilitation staff, and she reported going 11 days without pain medication despite numerous complaints.

On multiple occasions, therapy staff did not communicate the resident’s pain complaints and therapy refusals to nursing for assessment and intervention. On 10/15/2025, a physical therapy note documented a refusal to ambulate without a reason, and the MAR showed no pain medication given that day; the PTA later stated the resident had complained of pain and that he did not notify nursing. On 10/22/2025, the physical therapy note documented joint pain and refusal to ambulate, with no corresponding pain medication on the MAR, and the PTA acknowledged the resident continued to complain of left knee pain and that he should have notified the charge nurse. On 1/27/2026, the resident told an occupational therapist she was in pain and declined an OT session, but the OT did not notify the assigned LVN, who reported she had not been informed of any pain complaints. During interviews and observation on 1/27/2026, the resident was seen holding her knee, appearing uncomfortable, and reporting 10/10 pain and that staff were not addressing her pain.

Nursing staff also failed to document numerical pain reassessments after administering pain medication and did not implement ordered pharmacologic interventions for new-onset severe pain. Review of Medication Administration Progress Notes for 12/2025 through 1/2026 showed that numerical pain ratings were not documented to evaluate the effectiveness of pain medication on several dates, which RN 1 confirmed meant the facility did not accurately assess and track the medication’s effectiveness. A change of condition note on 10/28/2025 documented new-onset 10/10 pain in both arms, both legs, and the coccyx; the resident refused Tylenol and ibuprofen and was prescribed Tramadol 50 mg PO every eight hours PRN for severe pain. The MAR contained no documentation that Tramadol or any other pain medication was administered following this report of 10/10 pain, and the DON stated the resident’s pain was not treated as ordered. Review of 2025 IDT notes showed no interdisciplinary evaluation or modification of pain management interventions after the new-onset 10/10 pain was reported, which the DON stated was a missed opportunity to address the resident’s pain management needs. The facility’s pain management policy required IDT review of pain assessments, resident-centered care planning, administration and documentation of pain medications, timely re-evaluation of pain within one hour after medication, and physician notification for new-onset or unrelieved pain, which were not followed in this case.