Failure to Accurately Assess and Document Resident Pain Level
Penalty
Summary
The deficiency involves the facility’s failure to accurately assess and document a resident’s pain level in accordance with physician orders, the care plan, and facility policy. The resident had been admitted with diagnoses including joint replacement surgery and end stage renal disease requiring hemodialysis. The resident’s MDS indicated she was able to make reasonable decisions and required only partial to supervision-level assistance with ADLs. Physician orders and the care plan directed staff to assess and monitor the resident’s pain level every shift and to manage her pain, including the use of Hydrocodone-Acetaminophen 5/325 mg as needed for moderate to severe pain. On the date in question, the resident’s vital signs were taken in the morning, and the Weights and Vitals Summary documented blood pressure and heart rate but did not include a pain level, despite the order to assess pain every shift. The MAR for that month showed a recorded pain level of 3 for the day shift on that date and an order to administer Hydrocodone-Acetaminophen 5/325 mg every four hours as needed for pain levels 4–10. The MAR also showed that the resident received one tablet of Hydrocodone-Acetaminophen at 11:01 a.m. In interviews, the resident reported that one morning, a few hours after breakfast, she told an LVN that her pain was getting worse, but the LVN did not pay attention, did not ask questions about her pain, and the resident ultimately called a family member because the pain was making her anxious. The LVN later stated she had checked the resident’s vital signs around 9:17 a.m. but did not document the pain level with the vital signs, and that she identified the resident’s pain level as 6 around 11:00 a.m. but did not document that pain level in the medical record at that time. The DON confirmed that the LVN should have documented complete vital signs, including pain, and updated and recorded the accurate pain level during the shift to reflect the resident’s condition and ensure continuity of care, consistent with the facility’s pain assessment and management policy requiring documentation of the resident’s reported level of pain with adequate detail.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.