Failure in Pain Management for Two Residents
Penalty
Summary
The facility failed to provide adequate pain management for two residents, as evidenced by the lack of non-pharmacological interventions prior to administering narcotic pain medication for one resident and the failure to implement appropriate interventions for another resident's continued pain. Resident 60, admitted with multiple rib fractures, had physician orders for as-needed Oxycodone. However, in January 2025, staff administered the medication 30 times, with 23 instances lacking documented evidence of non-pharmacological interventions. Similar patterns were observed in February and March 2025. Interviews with the Nursing Home Administrator and Director of Nursing confirmed the inconsistency in attempting non-pharmacological interventions before administering narcotic pain medication. Resident 15, admitted with chronic obstructive pulmonary disease and emphysema, had a care plan for pain related to arthritis, which included non-pharmacological interventions such as repositioning and therapy evaluation. Despite complaints of pain and a new diagnosis of lumbar vertebrae compression fractures, there was no documented evidence that the resident was offered as-needed acetaminophen or other alternative pain-relief interventions. The Director of Nursing confirmed the facility's failure to develop and implement appropriate pain management interventions for Resident 15's continued pain.
Plan Of Correction
The facility cannot retroactively correct the nonpharmacological intervention documentation presence prior to as needed oxycodone administration for resident 60 for 1/13/25-1/26/25 and 2/13/25. All other administrations have nonpharmacological interventions documented in the Medication Administration Record. Resident 15 has remained free of verbal/nonverbal complaints of pain since 1/13/25, with dates of pain documented only on 1/12-1/13/25. Facility will assess current residents with as needed pain medications to verify presence of nonpharmacological intervention(s) documentation prompt prior to medication administration in the medical record and administer as needed/indicated. Nursing staff will be re-educated on documentation and implementation of nonpharmacological intervention(s) prior to medication administration. Audits will be done on new admissions with as needed pain medication to ensure presence of nonpharmacological intervention(s) documentation prior to medication administration in the MAR weekly x 4 weeks, then monthly x 2 months. Results will be reviewed at monthly QAPI meeting.