Failure to Offer and Document Non-Pharmacological Interventions Prior to Opioid Administration
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions were offered and documented prior to administering opioid pain medication for a resident with a history of hip fracture, falls, and osteoporosis with pathological fractures. The resident's care plan, revised on 4/8/25, specified the use of non-pharmacological pain management strategies such as repositioning, reduced stimuli, warm towel, distraction, music, and massage. Although a previous physician order required non-pharmacological interventions before administering PRN pain medication, this order was discontinued on 4/7/25, and a new order for Hydrocodone-Acetaminophen as needed for severe pain was implemented. Medication administration records showed multiple instances of PRN pain medication given, but there was no documentation that non-pharmacological interventions were attempted prior to these administrations. The Director of Nursing confirmed the absence of such documentation in the resident's record.