Failure to Follow PRN Pain Medication Parameters and Documentation Standards
Penalty
Summary
Facility staff failed to provide pain management services consistent with professional standards of practice for a resident admitted with multiple medical diagnoses, including a right femur fracture, atrial fibrillation, COPD with exacerbation, and respiratory failure. The resident had physician orders for PRN Tylenol 325 mg (2 tablets every 4 hours as needed, not to exceed 3000 mg/day) without specific administration parameters, and for PRN Oxycodone 5 mg (1 tablet every 6 hours as needed for pain scores 6-10). Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed that Oxycodone was administered multiple times for pain scores below the ordered threshold (pain scores of 4 or 5), which was outside the prescribed parameters. Additionally, PRN Tylenol was administered 17 times for pain scores ranging from 3 to 8, despite the absence of defined parameters for its use. Interviews with nursing staff confirmed that pain medication should be administered according to physician-ordered parameters, and deviations from these parameters should be documented and justified in the resident's progress notes. However, there was no documentation explaining why Oxycodone was given outside the ordered parameters. The Director of Nursing verified these findings and acknowledged the lack of documentation and the absence of administration parameters for PRN Tylenol.