Failure to Implement Non-Medication Pain Interventions as Ordered
Penalty
Summary
The facility failed to implement non-medication pain interventions as ordered by the physician for a resident with chronic pain syndrome, low back pain, right leg pain, and polyneuropathy. The resident, who was cognitively intact, experienced frequent pain that interfered with sleep and was prescribed both pharmacological and non-pharmacological pain management strategies. Physician orders specifically required that non-medication pain interventions be offered prior to administering PRN pain medications. However, review of the resident's Medication Administration Record (MAR) and nursing notes showed that non-pharmacologic interventions were not documented or offered prior to the administration of PRN pain medications, despite the resident receiving Norco for moderate to severe pain on multiple occasions. Interviews with nursing staff and the DON confirmed that non-medication pain interventions were expected to be documented in the MAR when PRN pain medications were given, but this was not done for the resident in question. The DON also acknowledged that the resident's care plan did not specify non-medication pain interventions, even though such interventions were included in the physician's orders. The facility's pain management policy indicated that both pharmacological and non-pharmacological interventions may be implemented, but the required non-medication interventions were not provided or documented for this resident.