Failure to Implement Non-Pharmacological Pain Interventions and Monitor Side Effects
Penalty
Summary
The facility failed to initiate non-pharmacological interventions for pain management prior to administering as-needed pain medications for a resident with a lower back fracture and associated pain. Review of the resident's Medication Administration Records (MAR) for February and March 2025 showed multiple administrations of Methocarbamol and Oxycodone, both as-needed, without documentation that non-pharmacological interventions were attempted beforehand, despite physician orders listing several such interventions. Interviews with nursing staff and the Director of Nursing confirmed that the expectation was to try non-pharmacological methods before administering as-needed pain medications, but there was no evidence these were offered or documented prior to medication administration. Additionally, the facility did not adequately monitor for adverse side effects of the pain medications given to the resident. The lack of documentation and implementation of non-pharmacological interventions, as well as insufficient monitoring for medication side effects, were identified through record review and staff interviews. These failures were found during the review of the resident's care and medication records, as well as through direct questioning of facility staff and leadership.