Failure to Attempt Non-Pharmacological Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident by not attempting non-pharmacological interventions before administering narcotic pain medications. Resident 33, who was admitted with diagnoses including low back pain and muscle weakness, had physician orders for Tramadol and Oxycodone to be given as needed for pain. During November and December 2024, the resident received these medications multiple times without any documented attempts of non-pharmacological interventions prior to administration. The clinical record review and staff interviews confirmed that the facility did not consistently attempt or document non-pharmacological interventions before administering PRN narcotic pain medications. The Nursing Home Administrator and Director of Nursing acknowledged the lack of evidence for such interventions, which is a requirement under 28 Pa. Code 211.12(c)(d)(1)(5) Nursing Services.
Plan Of Correction
Step 1 - R-33 MAR was updated to include documentation of non-pharmacological interventions on 12/19/2024. Step 2 - Review of residents receiving prn pain medications to assure the "NPI" documentation in place. Step 3 - Education to licensed staff on the importance of offering and documenting non-pharmacological interventions prior to giving PRN pain medications. Step 4 - Random audits of residents receiving PRN pain medications to assure non-pharmacological interventions are in place and documentation completed. Weekly times 4 monthly times 2. DON or Designee. Step 5 - Results to QAPI Monthly times 2.