Failure to Care Plan Pain and Hospice Services for a Resident with Gangrene
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan that included measurable objectives and timeframes for a resident with significant pain and hospice involvement. The resident, an older male admitted with cerebrovascular disease, gangrene, unspecified knee pain, and osteoarthritis, had a significant change MDS showing severely impaired cognition and pain that frequently limited day-to-day activities. The MDS also documented that he received PRN pain medication and hospice services. The Care Area Assessment (CAA) for pain was triggered, but the care planning decision box for pain was not selected, indicating that this triggered area was not carried forward into the care plan. Record review showed that the resident’s care plan, last revised in early March, did not include his pain related to gangrene, knee pain, osteoarthritis, or his receipt of hospice services, despite active physician orders for scheduled and PRN opioid analgesics specifically for pain related to gangrene and an order for hospice admission and pronouncement at time of death. During an interview, the resident reported having pain due to gangrene and was unsure if he received his pain medication, while a family member stated that sometimes nursing staff were not around when pain medications were due, although overall they usually provided them when he had pain. The family member also stated that hospice had spoken to the facility about ensuring he received his pain medications. When the Corporate Compliance Nurse accessed the care plan in edit view, she stated that the area for potential uncontrolled pain appeared to have been triggered and added, and she added interventions under a different section rather than under pain. However, a previously saved copy of the care plan did not include pain, and the most recent version showed pain with an initiation date corresponding to the survey date, which she acknowledged was not correct. The MDS nurse later stated that when completing the resident’s last MDS, the pain item was not selected and should have been, and that if it had been selected it would have triggered adding pain to the care plan. The MDS nurse acknowledged that pain was not on the care plan and should have been so staff would know how to plan, treat, and monitor for pain. The DON stated that pain should be on the resident’s care plan because it affected his daily care, activities, and eating habits, and that hospice should be on the comprehensive care plan as well.
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