Failure to Attempt and Document Non-Pharmacological Pain Interventions Prior to Administering Oxycodone
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions were attempted and documented prior to administering as-needed oxycodone for pain management for one resident. The resident, who had diagnoses including sarcoma, right knee pain, and post-surgical aftercare, had physician orders specifying that non-pharmacological pain interventions such as repositioning, dimming lights, distraction, relaxation techniques, hot/cold applications, music, and massage should be tried and their effectiveness documented before administering pain medication. However, review of the Medication Administration Record (MAR) revealed that on multiple occasions, there was no documentation that these interventions were attempted prior to giving oxycodone. Interviews with nursing staff confirmed that non-pharmacological interventions were not always offered or documented before administering pain medication, despite clear physician orders and facility policy requiring this protocol. The Director of Nursing also acknowledged that non-pharmacological interventions should be tried first to assess their effectiveness before considering medication. The facility's policy emphasized the importance of these interventions and the potential adverse effects of pain medications, but the required steps were not consistently followed or documented for the resident in question.