Failure to Follow Pain Management Protocols and Physician Orders
Penalty
Summary
Facility staff failed to follow established pain management protocols for a resident with a diagnosis of malignant neoplasm of the lung. The resident had a physician order for hydrocodone-acetaminophen to be administered as needed for moderate pain, specifically for pain levels rated between 5 and 7 on a numeric pain scale. However, clinical record review showed that staff administered the narcotic pain medication 19 times in June and 5 times in July without attempting or documenting non-pharmacological interventions prior to medication administration, as required by standard nursing practice and pain management guidelines. Additionally, the medication was administered outside the parameters of the physician's order on several occasions, including for pain levels categorized as severe, mild, or even when the resident reported no pain. These findings were confirmed through review of the Medication Administration Record and staff interviews, indicating that the facility did not ensure pain medications were administered according to physician orders and failed to consistently attempt or document non-pharmacological interventions prior to the use of as-needed narcotic pain medications.