Failure to Provide and Document Non-Pharmacological Interventions and Adhere to Medication Parameters
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary medications by not providing or documenting non-pharmacological interventions prior to administering pain medications, not following medication parameters, and not reassessing the necessity of medications when abnormal vital signs were present. For one resident who was cognitively intact and receiving opioid medication for pain, physician orders required non-pharmacological interventions such as repositioning and diversional activities before medication administration. However, medication and treatment records showed no documentation that these interventions were offered or completed, and staff confirmed that this documentation was missing. Another cognitively intact resident with congestive heart failure had orders for Oxycodone with specific pain level parameters and required non-pharmacological interventions before administration. The medication administration record showed that higher doses were given for pain levels below the ordered threshold, and there was no documentation that non-pharmacological interventions were attempted prior to medication administration. Additionally, this resident was on multiple antihypertensive medications and diuretics, but there were no parameters in place for holding these medications despite documented low blood pressure readings. A third resident, who was moderately cognitively impaired, had orders for hydromorphone for severe pain with instructions to attempt non-pharmacological interventions first. The medication was administered for pain scores below the ordered threshold, and there was no documentation of non-pharmacological interventions. This resident also received a diuretic despite low blood pressure readings, without provider notification or reassessment. Staff interviews confirmed that expectations for documentation and adherence to medication parameters were not met in these cases.