Failure to Follow Physician Orders and Document Non-Pharmacological Interventions in Pain Management
Penalty
Summary
Nursing staff failed to follow physician orders for pain management for two residents with significant pain-related diagnoses. For one resident with acute pain due to trauma, spinal stenosis, and vertebral fractures, the care plan and physician orders specified that opioid pain medication should only be administered for severe pain rated 7-10 on the pain scale. However, nursing staff administered the medication for pain levels as low as 5 and 6, which was below the ordered threshold. Additionally, there was no documentation of non-pharmacological interventions being attempted prior to administering the opioid medication, as required by facility policy and the resident's care plan. For another resident with osteoarthritis, hip and knee pain, and a contracture, the physician order specified that opioid pain medication was to be given for moderate (4-6) and severe (7-10) pain. Despite this, nursing staff administered the medication for pain levels of 2 and 3, which are considered mild and not within the parameters of the physician's order. Again, the clinical record lacked documentation of non-pharmacological interventions prior to the administration of the opioid medication. Interviews with the Director of Nursing confirmed that staff administered opioid pain medications outside of the prescribed pain scale parameters for both residents and that there was no documentation of non-pharmacological interventions prior to medication administration. These actions were inconsistent with both facility policy and professional standards of practice for pain management.