Failure to Promptly Assess and Manage Resident’s Severe Mouth Pain
Penalty
Summary
The deficiency involves the facility’s failure to promptly assess and manage a resident’s complaints of severe mouth pain during a breakfast meal service. During a dining room observation, the resident repeatedly stated she had a bad toothache, guarded her right lower jaw, grimaced, cried out that it hurt badly, and declined breakfast. An RN walked past the resident after the initial complaint without acknowledging the pain, then sat nearby to assist another resident. Over the next several minutes, the resident continued to vocalize significant pain and insist she needed to go to a dental appointment, while CNAs moved in and out of the dining room and the RN continued assisting another resident. When a CNA asked the RN about the timing of the resident’s dental appointment, the RN shrugged and stated she was not looking, and did not immediately assess the resident or check for available pain interventions. The resident’s crying out intensified, and only after this escalation did the RN ask a CNA to get the DON. The DON then informed the resident that her dental appointment was not that day and indicated staff would obtain Orajel. The RN left the dining room, and Orajel was administered on a disposable mouth sponge, followed by acetaminophen a few minutes later, after the DON propelled the resident toward her room while the resident continued to state she was in horrible pain. The resident’s clinical record showed diagnoses including Parkinson’s disease, dementia, seizures, anxiety, chronic pain, and a pain disorder related to psychological factors. Orders included scheduled and PRN acetaminophen, Tramadol, and PRN Orajel, and a recent MDS documented that the resident was moderately cognitively impaired, frequently in pain, and that pain frequently interfered with sleep and daily activities, with the resident describing her pain as severe. The care plans identified the resident as at risk for pain and called for administering pain medications as ordered, assessing and documenting effectiveness, notifying the physician if pain was unrelieved or worsening, and offering nonpharmacological interventions. Interviews with nursing staff and the DON confirmed that the RN should have assessed the resident when she first complained of mouth pain and that pain complaints should be addressed first, consistent with the facility’s pain management policy requiring necessary care and services to manage pain based on reported intensity.
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