Failure to Document Nonpharmacological Pain Interventions Prior to PRN Opioid Administration
Penalty
Summary
The facility failed to ensure that nurses documented the use of nonpharmacological interventions prior to administering as-needed (PRN) hydromorphone to a resident with a left rib fracture. The resident, who had intact cognition and required maximal assistance with most activities of daily living, had a physician's order specifying that nonpharmacological interventions should be attempted before administering opioid medication for severe pain. However, review of the Medication Administration Record showed that the resident received hydromorphone on multiple occasions, and there was no documentation indicating that nonpharmacological interventions were attempted prior to medication administration. During interviews, the MDS Coordinator was unable to locate any documentation of nonpharmacological interventions before the administration of hydromorphone, and the Director of Nursing acknowledged the importance of such interventions to avoid unnecessary medication. The facility's pain management policy, which was current at the time, required the use of various nonpharmacological strategies before medicating for pain, but these were not documented as being attempted for the resident in question.