Failure to Implement Pain Scale and Non-Pharmaceutical Interventions Prior to PRN Narcotic Administration
Penalty
Summary
The facility failed to implement a pain scale for the administration of Hydromorphone as recommended by the consultant pharmacist and agreed to by the nurse practitioner for a resident with diagnoses including encephalopathy, osteoarthritis of the left shoulder, and chronic tension headaches. Despite the recommendation, review of the resident's Medication Administration Records (MAR) for March and April 2025 showed no evidence that a pain scale was added to the physician's order. Additionally, documentation did not show that non-pharmaceutical interventions were attempted prior to administering the PRN Hydromorphone, as required. The resident received Hydromorphone multiple times for varying pain levels, including instances where pain was documented as zero.