Failure to Follow Physician Orders for Pain Management
Penalty
Summary
The facility failed to provide the highest practicable care regarding physician-ordered pain medications for a resident requiring pain management. Clinical record review showed that the resident had physician orders for acetaminophen to be administered as needed (PRN) for mild or moderate pain, with specific instructions for use based on pain levels. Despite these orders, staff administered acetaminophen for pain levels that were documented as severe (pain scores of 7-10), which exceeded the parameters set by the physician's orders. Multiple instances were noted where acetaminophen, ordered for mild pain, was given when the resident reported pain levels of 7, 8, or 9. The medication administration records (MARs) documented several occasions where staff did not adhere to the prescribed pain management protocol, administering medication outside the specified pain level range. This was confirmed during an interview with the Nursing Home Administrator and Director of Nursing. The deficiency was cited under 28 Pa. Code 211.12(c)(d)(1)(3)(5) for nursing services, as the facility did not ensure safe and appropriate pain management in accordance with physician orders.