Failure to Implement Non-Pharmacological Pain Interventions
Penalty
Summary
The facility failed to implement non-pharmacological interventions for pain management as required by its own policy and professional standards. Review of the facility's Pain Evaluation and Management Policy indicated that care plans should include both pharmacologic and non-pharmacologic interventions, and that these plans should be reviewed and revised as needed. For one resident with a left femur fracture, the care plan did not include any non-pharmacological interventions for pain, despite the resident being at risk for pain related to the fracture. Clinical records showed that the resident was prescribed and received multiple doses of oxycodone for severe pain, but there was no documented evidence that non-pharmacological interventions were offered or provided. The Medication Administration Record confirmed frequent administration of opioid medication, and the Director of Nursing acknowledged that non-pharmacological interventions were not being used for this resident, despite facility policy requiring such measures prior to pharmacological interventions.