Failure to Use Non-Pharmaceutical Pain Interventions and Monitor Medication Side Effects
Penalty
Summary
The facility failed to implement non-pharmaceutical interventions prior to administering as-needed pain medications for three residents and did not monitor for side effects of pain and anti-depressant medications for two residents. Clinical record reviews for residents with orders for pain medications such as Oxycodone HCl, Hydrocodone-Acetaminophen, and Percocet did not show evidence that non-pharmacological interventions were attempted before medication administration. Additionally, there was no documentation of ongoing monitoring for medication side effects as required by the facility's pain management policy. Specifically, one resident with a history of moderate to severe pain and another with diagnoses including a left femur fracture and left shoulder dislocation received as-needed opioid pain medications without documented attempts at non-pharmaceutical pain management. The records also lacked evidence of side effect monitoring for both pain and anti-depressant medications. These findings were confirmed in interviews with the Nursing Home Administrator and DON, who acknowledged that non-pharmaceutical interventions and side effect monitoring were not performed.