|§483.25(k) Pain Management. |
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to perform a thorough pain assessment and offer non-pharmacological interventions for pain relief for one of 88 residents reviewed (Resident 37).
The facility's policy regarding pain management, dated March 22, 2019, revealed that pain observation documentation was to include characteristics of the resident's pain intensity, pattern, location and radiation, frequency, timing and duration, along with verbal and non-verbal signs and symptoms of pain. Licensed nurses were to document both pharmacological (medicines) and non-pharmacological interventions, and the effectiveness of pain management in the nursing progress notes.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 37, dated August 27, 2019, indicated that the resident was able to be understood, could understand, required limited to extensive assistance from staff for daily care tasks, had frequent complaints of moderate pain, and received "as needed" pain medicine. The resident's care plan, dated September 5, 2019, revealed that the resident had a history of pain related to fractures, and staff were to assess and document pain characteristics such as quality, severity, location, onset, duration and precipitating and relieving factors.
Physician's orders for Resident 37, dated June 1, 2019, included orders for the resident to receive 20 milliliters (ml) of liquid Tylenol (160 milligrams per 5 ml) to be administered by mouth for headache, mild discomfort, or a fever of 101 degrees Farenheit lasting greater than 24 hours. Physician's orders dated August 21, 2019, included orders for one 5/325 milligram (mg) tablet of Norco (an opioid pain medication) to be administered every four hours as needed for pain.
Resident 37's nursing notes and Medication Administration Records (MAR's) for September, October and November 2019 revealed that on the following dates and times, the resident had complaints of pain in various locations, and staff administered Norco:
September 2 at 5:18 p.m.
September 3 at 5:07 p.m.
September 5 at 11:20 a.m.
September 6 at 8:20 a.m.
September 10 at 8:10 a.m.
September 15 at 7:45 a.m.
September 18 at 8:16 a.m.
September 26 at 7:54 a.m.
September 28 at 8:03 a.m.
September 29 at 7:39 a.m.
October 1 at 8:02 a.m.
October 3 at 9:10a.m.
October 4 at 9:10 a.m.
October 9 at 10:15 a.m. and 6:20 p.m.
October 14 at 1:06 p.m.
October 22 at 9:10 a.m. and 5:10 p.m.
October 23 at 8:30 a.m.
October 24 at 7:50 a.m.
October 26 at 8:16 a.m.
October 28 at 8:40 a.m.
October 31 at 8:10 a.m.
November 1 at 8:02 a.m.
November 4 at 11:30 a.m.
November 6 at 8:06 a.m.
November 7 at 6:20 a.m.
November 9 at 8:06 p.m.
November 13 at 8:35 a.m.
November 14 at 8:16 a.m.
November 15 at 8:12 a.m.
November 18 at 8:08 a.m.
November 19 at 8:12 a.m.
November 21 at 8:28 a.m.
There was no documented evidence in the resident's clinical record that staff assessed the resident's complaints of pain, including characteristics of the pain such as intensity, pattern, and radiation, frequency, timing and duration, along with verbal and non-verbal signs and symptoms of pain, nor did staff document any attempts at non-pharmacological interventions prior to medicating the resident with Norco.
Interview with Licensed Practical Nurse 9 on November 21, 2019, at 2:03 p.m. revealed that she was very familiar with Resident 37 and was assigned to give him medications on most days she worked. She confirmed that the physician's orders for Norco did not include parameters for what type or level of pain to administer it for, versus giving the Tylenol. She indicated that if the resident complained of a headache she would give him Tylenol, and she administered Norco for back pain.
Interview with Registered Nurse Supervisor 8 on November 22, 2019, at 11:50 a.m. confirmed that there was no documented evidence that staff assessed Resident 37's above complaints of pain, and no documented evidence that staff attempted non-pharmacological interventions prior to medicating the resident with Norco.
Interview with the Director of Nursing on November 25, 2019, at 1:40 p.m. confirmed that staff should be following the facility's pain management policy regarding documentation of pain assessments and non-pharmacological interventions.
42 CFR 483.25(k) Pain Management.
Previously cited 10/25/18.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
Previously cited 3/28/19, 10/25/18.
| ||Plan of Correction - To be completed: 01/07/2020|
Resident 37 was assessed for pain and the care plan was updated to include non-pharmacological interventions for pain relief. Unit licensed staff were educated on performing a thorough pain assessment.
An audit of residents who trigger in the Minimum Data Set for pain will be conducted to ensure a thorough pain assessment has been completed and non-pharmacological interventions for pain relief were in place on the care plan.
The Pain Management Policy was updated to include: Non-pharmacological interventions should be attempted prior to administering any pain medication. Non-narcotic pain medication should be administered first and effectiveness evaluated unless severe pain is identified, requiring narcotic medication. The Medication Administration Policy was updated to include Licensed staff (Registered Nurses (RNs)/Licensed Practical Nurses (LPNs)will assess/evaluate for and document in the progress notes characteristics of the pain such as intensity, pattern, and radiation, frequency, timing and duration, along with verbal and non-verbal signs and symptoms of pain, as well as non-pharmacological interventions prior to medicating residents. Licensed staff (RNs/LPNs)will be educated on the policy changes.
Random quality reviews of progress notes regarding pain assessments and non-pharmacological interventions for pain relief will be conducted by the Registered Nurse Supervisors to ensure that non-pharmacological interventions were attempted prior to administering any pain medication.
This review will be conducted daily for four weeks, weekly for four weeks, then bi-weekly for one month. Results will be reported at regularly scheduled quality improvement meetings.