Inadequate Pain Management and Care Planning for Resident With Chronic Severe Pain
Penalty
Summary
The facility failed to provide adequate pain management for a resident with chronic pain in the knees, lower back, and shoulders. The resident had diagnoses including cardiomyopathy, COPD, depressive disorder, need for assistance with personal care, and muscle weakness, and had intact cognition per a recent MDS. The MDS documented that the resident frequently experienced pain at a level of 10 on a 0–10 scale, which occasionally affected sleep, and that the resident was on a scheduled pain medication regimen and received nonpharmacological interventions, with no PRN pain medications. The Pain CAA indicated the resident took an opioid every six hours for low back pain and was to be monitored every shift and as needed for any pain. The care plan documented use of an opioid for chronic joint and lower back pain and directed staff to assess pain type, location, and characteristics before and after administration of PRN medication, and stated that long-acting opioid use was appropriate based on the resident’s history, but it lacked specific directions for nonpharmacological pain interventions. Physician orders included hydrocodone-acetaminophen 10-325 mg every six hours for low back pain, diclofenac gel to the right knee three times daily, and an order to monitor pain every shift related to PRN hydrocodone use, but there was no active PRN order for breakthrough pain. A physician progress note documented the resident reporting pain at level 10 in the right leg and knee, described as achy with pins and needles and worsened by movement, while taking hydrocodone 10 mg every six hours. During surveyor observation, the resident reported significant ongoing pain in joints, knees, shoulders, and lower back despite routine pain medication. A CNA reported the resident did not always verbalize pain but showed signs such as facial expressions and decreased appetite, which she reported to the nurse. A licensed nurse confirmed that physician orders lacked PRN pain medication despite reports of pain at level 10 and that the care plan and orders lacked direction for nonpharmacological pain interventions. An administrative nurse acknowledged the resident was on routine hydrocodone without breakthrough pain medication, had no nonpharmacological interventions in the care plan, and that there had been no assessment of the resident’s acceptable pain level or consultation for ongoing pain, in the context of a facility policy addressing unnecessary medications and appropriate duration based on assessment and therapeutic goals.
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.