Failure to Document Nonpharmacological Pain Management Interventions
Penalty
Summary
The facility failed to document the use of nonpharmacological interventions for pain management for two residents who were prescribed pain medications. For one resident, a physician order was in place for Roxicodone to be administered as needed for pain or prior to physical therapy. The resident's care plan specified that nonpharmacological interventions such as turning and repositioning, music, television, low light, hot or cold applications, and noise reduction should be used for pain management. However, a review of the Treatment Administration Record (TAR) revealed no documentation that these interventions were attempted or implemented prior to administering pain medication. Similarly, another resident had a physician order for tramadol for pain, and their care plan also directed nursing staff to use nonpharmacological pain management strategies. Upon review, there was no evidence in the TAR that these interventions were documented as being used before administering the medication. An interview with the Director of Nursing confirmed that the care plan interventions should have been added to the TAR and acknowledged the lack of documentation to validate the use of nonpharmacological measures.