Failure to Follow Pain Management Protocol and Physician Orders
Penalty
Summary
The facility failed to follow its pain management protocol and physician's orders for a resident requiring pain management services. The resident had a physician's order for hydrocodone-acetaminophen to be administered prior to therapy sessions, but the medication was given daily at a set time in the morning, regardless of whether therapy was scheduled or not. Documentation and staff interviews confirmed that the medication was administered even on days when the resident did not receive therapy, and without coordination between nursing and therapy staff regarding therapy schedules. The order was also incorrectly entered in the electronic medication administration record (MAR), leading to routine administration rather than as needed before therapy. Additionally, the resident had two PRN (as needed) pain medication orders—acetaminophen and a lidocaine patch—without specified pain level parameters for administration. Staff interviews revealed that PRN pain medications should have clear pain level guidelines, and the DON confirmed that orders for multiple PRN pain medications should specify the pain level at which each should be administered. Review of the MAR showed that both PRN medications were administered for a documented pain level of zero, which staff acknowledged should not occur, as zero indicates no pain. These failures resulted in the resident receiving unnecessary pain medication and being at risk for inadequate pain control during therapy sessions. The facility's own policies required pain medications to be administered as ordered, and staff confirmed that the observed practices did not align with these requirements. The lack of coordination between nursing and therapy, incorrect order entry, and absence of pain level parameters for PRN medications directly contributed to the deficiency.