Failure to Ensure Residents Are Free from Unnecessary Medications Due to Inadequate Pain Management Practices
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary medications by not providing or documenting non-pharmacological interventions (NPIs) for pain management, not establishing clear parameters for medication administration, and not consistently offering non-opioid medications prior to opioid use. For one resident with chronic pain and muscle spasms, morphine was administered multiple times without documented attempts to use NPIs or offer non-opioid alternatives such as ibuprofen, despite care plans indicating NPIs should be used. Staff interviews confirmed that NPIs and non-opioid medications were not consistently offered or documented, and medication orders lacked specific parameters for administration. For two other residents, physician orders required assessment for pain and the use of NPIs with documentation of their effectiveness. However, the medication administration records showed that NPIs were documented as used daily, even when no pain was reported, and there was no documentation of the effectiveness of these interventions. Progress notes did not specify which NPIs were used or their outcomes, and staff acknowledged that documentation was incomplete and often copied from previous entries. Another resident with significant cognitive impairment and end-of-life care needs had morphine orders that were not linked to NPI instructions, and staff did not document attempts to use NPIs prior to administering morphine. The morphine orders also lacked specific pain scale parameters, and there was no evidence that the facility was monitoring for adverse side effects of opioid administration. Staff interviews confirmed that these documentation and monitoring practices were not being followed as required.