Failure to Attempt Non-Pharmacological Pain Management
Penalty
Summary
The facility failed to adhere to its pain management policy by not attempting non-pharmacological interventions before administering as-needed pain medication to a resident. The policy, last reviewed in January 2025, mandates that non-pharmacological methods should be tried prior to giving pain medication prescribed on an as-needed basis. Resident 18, who had diagnoses including muscle weakness, cellulitis, and chronic ulcers on the left foot, was prescribed tramadol for severe pain. However, the medication administration records for December 2024 and January 2025 showed no evidence of attempts at non-pharmacological interventions before administering tramadol on multiple occasions. Interviews with the Director of Nursing confirmed the lack of documentation for these interventions, which should have been recorded in the MAR.
Plan Of Correction
Resident 18 discharged on 1/9/2025. Residents with PRN pain medication orders will be audited to determine compliance with non-pharmacological interventions prior to administration of pain medication. DON and/or nursing supervisor will conduct reeducation for licensed nurses reinforcing the need to attempt and document non-pharmacological interventions prior to administration of pain medications per facility policy. DON or designee will conduct routine audits to verify compliance with documentation of non-pharmacological interventions prior to administration of pain medications. Audit will be conducted weekly for the first 4 weeks and then monthly. Audit results will be reviewed during the monthly Quality Assurance Committee Meetings.