Failure to Implement Nonpharmacological Pain Interventions and Specify PRN Pain Parameters
Penalty
Summary
The facility failed to implement nonpharmacological interventions for pain management and did not ensure that pain medications were administered according to professional standards of practice for one resident reviewed. Record review showed that the resident had active physician orders for PRN Oxycodone and Acetaminophen for pain, as well as orders and care plan interventions specifying the use of nonpharmacological methods such as repositioning, distraction, activity involvement, and other comfort measures prior to administering PRN pain medication. However, documentation in the Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not show evidence that these nonpharmacological interventions were implemented or recorded as required. Additionally, the PRN pain medication orders for the resident did not include specific pain parameters to guide nursing staff on when to administer each medication based on the resident's pain level. Interviews with nursing staff and the DON confirmed that pain parameters were missing from the orders and that nonpharmacological interventions were not documented prior to medication administration. The facility's pain management policy required the use of appropriate pain scales and documentation of both pharmacological and nonpharmacological treatments, but these standards were not met in this case.