Failure to Incorporate Ordered Non-Pharmacological Pain Interventions Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize comprehensive care plans to include ordered non-pharmacological pain interventions for three residents. Facility policies on Pain Recognition and Management and Comprehensive Person-Centered Care Planning require that pain management be consistent with professional standards, include both pharmacological and non-pharmacological interventions, and that the interdisciplinary care plan be reviewed and revised after each assessment. For Resident 4, who had a left femoral fracture, a physician’s order dated 11/26/25 specified non-pharmacological pain interventions such as repositioning, dim light/quiet environment, relaxation, distraction, music, and massage as needed. However, the pain care plan initiated on 11/28/25 only included administering medication as ordered and did not incorporate these non-pharmacological interventions. During interviews and concurrent record reviews, LVN 7 and the DON acknowledged that the current plan of care for pain should have reflected these interventions. For Resident 19, who had acute/chronic pain related to UTI, stroke, and seizures, a physician’s order dated 1/21/26 also included the same set of non-pharmacological pain interventions. The care plan for acute/chronic pain initiated on the same date listed interventions such as administering medication as ordered but did not include the ordered non-pharmacological measures. Similarly, Resident 27, who reported on-and-off abdominal and lower back pain and had acute pain related to recent surgery, pressure injuries, medical condition, and impaired mobility, had a physician’s order dated 12/17/25 for the same non-pharmacological pain interventions. The pain care plan initiated on 12/18/25 again only reflected medication administration and omitted the non-pharmacological interventions. LVN 7 and the DON confirmed during interviews and record reviews that the residents’ current pain care plans should have included these non-pharmacological interventions, but they were not incorporated.
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