Failure to Follow Through on Pain Management Orders and Referrals
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with the resident’s comprehensive assessment, care plan, physician orders, and the resident’s goals and preferences. A cognitively intact resident with diagnoses including unspecified low back pain, anxiety, depression, and schizophrenia was care planned for back pain with interventions to administer pain medications as ordered, monitor pain characteristics and effectiveness of treatment, and refer to pain management as ordered. The resident’s MDS indicated frequent pain and use of scheduled, PRN medications and other interventions for pain. Progress notes documented that the resident reported chronic back pain and that existing pain medication was not effective. Physician orders and progress notes showed that an X‑ray, MRI of the lumbar and thoracic spine, and a pain management consult were ordered for low back pain, and later that the resident requested an increase in Tramadol after reporting higher doses received in the hospital. The primary care physician was notified, and a consent form was sent to the guardian for approval of the Tramadol increase, but the guardian refused and preferred that the resident attempt pain management first. The record contained no evidence that the ordered MRI was completed, no documentation of a pain management consult or referral follow‑through, and no documentation of attempts at alternative pain management as requested by the guardian. The facility also lacked policies and procedures for following through on physician referrals and orders, and for obtaining informed consent prior to medication increases or changes in the medication regimen.
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