Failure to Document Pain Symptoms and Non-Pharmacological Interventions Prior to PRN Narcotic Administration
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs by not documenting acute symptoms of distress or pain and not recording or attempting non-pharmacological interventions prior to administering as-needed (PRN) narcotic medications. The resident in question had a history of bilateral venous wounds and had recently sustained a fall, which she believed injured her hip. Her care plan included both pharmacological and non-pharmacological interventions for pain management, such as redirection, offering food, music, and ice/heat, and required monitoring and documentation of pain characteristics every shift and as needed. Despite these care plan directives, review of the resident’s Medication Administration Record (MAR) and progress notes revealed that PRN tramadol was administered multiple times without documentation of the resident’s pain symptoms or any non-pharmacological interventions attempted prior to giving the narcotic. Of the nine PRN doses administered, only one note provided a rationale for the medication, and none of the notes documented the use of non-pharmacological interventions before administering the narcotic. Interviews with staff confirmed that while non-pharmacological options were sometimes discussed, they were not consistently offered or documented, and pain assessments or interventions were not always recorded as required. The facility’s own medication administration policy required documentation of the resident’s specific complaint or symptoms for which PRN medication was given, but did not address the need to document non-pharmacological interventions. The director of nursing confirmed that both pain symptoms and attempted non-pharmacological interventions should be documented prior to administering PRN narcotics, but this was not consistently done in practice for the resident reviewed.