Failure to Document Pain Assessments and Non-Pharmacological Interventions Prior to PRN Opioid Administration
Penalty
Summary
The facility failed to consistently document pain assessments and the use of non-pharmacological interventions prior to administering PRN opioid pain medications for a resident with a history of left ankle fracture, anxiety, and schizophrenia. The resident was cognitively intact and experienced almost constant pain, receiving both scheduled and PRN pain medications, including oxycodone and tramadol. Review of the medication administration records over a two-month period showed that oxycodone was administered 69 times and tramadol 35 times, but only four pain assessments were documented for each medication. There was no documentation of any non-pharmacological interventions attempted before administering the PRN opioids. The Director of Nursing confirmed that the facility's standard practice required nursing staff to attempt non-pharmacological interventions and document both the intervention and the result prior to administering PRN pain medication, as well as to complete a pain assessment before opioid administration. However, the facility's medication management policy did not include any process or information related to the administration of opioid medications, contributing to the lack of consistent documentation and assessment.