Failure to Implement Individualized Pain Management and Non-Pharmacological Interventions
Penalty
Summary
The facility failed to develop and implement individualized pain management programs consistent with professional standards of practice for two residents. Clinical record reviews showed that both residents, who had diagnoses including Parkinson's Disease, chronic pain, and osteoarthritis, had physician orders for as-needed narcotic pain medications that required non-pharmacological interventions to be attempted prior to administration. However, medication administration records revealed that staff administered these pain medications multiple times without first attempting or documenting any non-pharmacological interventions, as required by the physician orders and facility policy. Additionally, there was an instance where pain medication was administered to a resident despite a pain score of zero, which was outside the parameters of the physician's order. Interviews with the Director of Nursing confirmed that the facility could not provide documentation supporting the use of non-pharmacological interventions prior to medication administration for the residents in question. These findings indicate a failure to follow both facility policy and physician orders regarding pain management.