Failure to Follow Individualized Pain Management Protocols and Physician Orders
Penalty
Summary
The facility failed to develop and implement an individualized pain management program consistent with professional standards of practice for a resident with osteoarthritis and muscle spasms. Despite a facility policy and physician orders requiring the use of non-pharmacological interventions prior to administering as-needed narcotic pain medication, staff repeatedly administered Hydrocodone-acetaminophen without documenting any attempt at non-pharmacological pain relief methods. The facility policy also required the use of a verbal numeric pain scale to guide medication administration, but staff did not consistently follow the pain scale parameters outlined in the physician's orders. Review of the resident's medication administration records over several months showed multiple instances where narcotic pain medication was given without prior non-pharmacological interventions and outside the prescribed pain scale range. Specifically, the medication was administered for both mild and severe pain, contrary to the order specifying use only for moderate pain. The Director of Nursing confirmed that there was no documentation to support the use of non-pharmacological interventions or justification for administering the narcotic outside the physician's parameters.