Failure to Follow Physician Orders and Non-Pharmacological Interventions for Pain Management
Penalty
Summary
A deficiency occurred when a resident was administered Tramadol HCl 50 mg on three occasions despite having a pain scale score of zero, which did not meet the physician's order specifying use only for moderate to severe pain. The clinical record also indicated that required non-pharmacological interventions, such as repositioning, distraction, massage, or other comfort measures, were not attempted or documented prior to administering the medication. The facility's policy required medications to be given according to physician orders and to utilize non-pharmacological interventions when appropriate, but these steps were not followed. During an interview, the DON was unable to provide a reason for the administration of Tramadol when the resident reported no pain.