Failure to Assess, Document, and Manage Ongoing Right Arm Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with its own pain policy and professional standards for one resident with significant neurologic and musculoskeletal impairments. The resident had a history of hemiplegia and hemiparesis affecting the right dominant side following a cerebral infarction, multiple joint contractures, severe cognitive impairment, and dependence on staff for all ADLs. Despite these conditions and the facility’s written Pain Assessment and Management policy requiring staff to assess for pain, recognize its presence, identify characteristics, address underlying causes, and develop and monitor pain interventions, staff did not consistently assess, document, or act upon ongoing signs and reports of right arm pain. Multiple CNAs reported that whenever they provided ADL care, including dressing and putting on the resident’s shirt, the resident would complain of right arm pain, moan, say “ouch,” or otherwise show signs of pain when the right arm was moved or touched. CNAs stated they informed various charge nurses/LVNs of the pain but could not recall specific names or dates, and they did not complete Stop and Watch forms to document these changes in condition as required. One CNA believed the pain complaints were “normal” due to the contracture and did not recognize the need for further assessment, while another CNA acknowledged that such pain could indicate a serious underlying issue. A nurse (LVN 1) reported observing facial grimacing during repositioning but did not document this as a change in condition because there were “no observed changes” in the resident’s pain. A family member posted a written note above the resident’s bed instructing staff to be mindful when touching, moving, or repositioning the resident’s right arm because of pain. LVN 2 acknowledged seeing this note but did not move or extend the arm to assess for pain, did not contact the family member to clarify the concern, did not notify the physician, and did not complete a change of condition report. The DON stated that charge nurses were responsible for completing change of condition reports when CNAs reported pain and that RNs were to assess the arm and notify the physician, but this process was not carried out. As a result of these failures to assess, document, and report the resident’s ongoing right arm pain and the posted family instruction, there was a delay in assessment, physician notification, and pain management interventions. The resident was later sent to a hospital for a change in condition, where imaging revealed a right shoulder fracture.
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