Routine Administration of Pain Medications Without Indication or Physician Clarification
Penalty
Summary
The facility failed to ensure that two residents' drug regimens were free from unnecessary medications, specifically pain medications, which were administered routinely without adequate indications or clarification of physician orders. For one resident with end stage renal disease and a BIMS score indicating cognitive intactness, Norco (hydrocodone-acetaminophen) and Tylenol Extra Strength were ordered and administered on a scheduled basis for pain, despite the resident consistently reporting a pain level of 0. Nursing staff confirmed that these medications were given as scheduled, regardless of the resident's reported pain level, and acknowledged that the resident did not have a chronic pain diagnosis. The Director of Nursing stated that nurses should have assessed for pain before administering these medications and should have clarified the orders with the physician. Another resident, diagnosed with a persistent vegetative state and non-verbal, was also administered acetaminophen routinely via g-tube for pain management, with scheduled doses given twice daily. The medication administration records showed that the pain level was documented as 0 most of the time. Nursing staff confirmed that the medication was given routinely, and the Director of Nursing again stated that the orders should have been clarified with the physician. In both cases, the facility's practice resulted in the regular administration of pain medications without documented evidence of pain or appropriate clinical justification, and without clarification of the physician's intent for routine versus as-needed administration. This practice was observed through medication administration records, staff interviews, and direct observation, and was acknowledged by both nursing staff and facility leadership as not aligned with proper medication management protocols.