Failure to Implement and Document Adequate Pain Management Interventions
Penalty
Summary
The deficiency involves the facility’s failure to sufficiently manage pain and implement or document non-pharmacological pain interventions for a resident admitted with frequent, moderate pain. On admission, the resident’s nursing assessment documented pain rated 5/10 over the prior five days, interfering with sleep and daily activities, and the PT evaluation and provider notes also identified pain that interfered with function and sleep. The resident had a diagnosis of transverse myelitis and a history of long-term opioid use, but arrived without an order for her usual Percocet. Initial documentation on the day of admission noted pain rated 5/10 but did not indicate what pain interventions were provided. Over the following days, the resident’s pain scores ranged from 5/10 to 9/10, with multiple documented assessments showing moderate to severe pain. Provider orders were obtained for a lidocaine 4% patch and PRN oxycodone-acetaminophen 10-325 mg every six hours, with the first Percocet dose administered two days after admission. Nursing progress notes and the MAR showed administration of Percocet for pain scores of 6/10 and 9/10, and one note indicated the medication was effective, but the records consistently lacked documentation of non-medication pain interventions attempted before or along with opioid use. The resident’s 48-hour baseline care plan noted admission with pain but did not include specific interventions to relieve pain, while the subsequent care plan listed non-medicinal interventions such as positioning, rest, and massage without evidence in the notes that these were implemented or documented. Interviews with staff, including the DON, confirmed that facility expectations and the written Pain Management Protocol required pain assessment on admission, use and documentation of non-pharmacological interventions, and obtaining alternative medications or interventions if there was a delay in pain medication. Staff acknowledged that non-medication interventions and thorough pain assessments, as well as documentation of interventions and resident responses, were not carried out or recorded for this resident as required.
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