Failure to Attempt Non-Pharmacological Pain Interventions Prior to PRN Opioid Administration
Penalty
Summary
The facility failed to follow its own policy regarding pain management for a resident with osteoarthritis of the right knee, who was cognitively intact and able to report pain levels. The facility's policy, last reviewed on April 8, 2025, required that non-pharmacological interventions be considered and attempted, either alone or in conjunction with medications, prior to administering pharmacological pain relief. Examples of such interventions included environmental adjustments, physical interventions, exercise, and cognitive or behavioral strategies. A review of the resident's clinical record and medication administration record (MAR) revealed that, over a period from March 1, 2025, through April 24, 2025, opioid pain medication (Oxycodone HCl 5mg) was administered on an as-needed (PRN) basis for reported moderate to severe pain on multiple occasions. On each of these occasions, there was no documented evidence that non-pharmacological interventions were attempted prior to the administration of the opioid medication, despite the resident's pain levels being within the range specified for PRN use. An interview with the Director of Nursing (DON) confirmed the absence of documentation regarding the use of non-pharmacological pain management strategies before administering opioid medication. This lack of documented attempts to use alternative pain management methods prior to pharmacological intervention constituted a failure to comply with both facility policy and regulatory requirements.