Failure to Use Non-Pharmaceutical Interventions and Monitor Side Effects
Penalty
Summary
The facility failed to ensure that non-pharmaceutical interventions were attempted prior to administering pain medication for one resident. Specifically, a resident with an order for Oxycodone 10 mg every eight hours as needed for moderate to severe pain received the medication on multiple occasions, but there was no evidence in the clinical record that non-pharmaceutical interventions were tried before administering the medication. This was confirmed by the Director of Nursing during an interview, who acknowledged that such interventions were not attempted prior to giving the pain medication. Additionally, the facility did not monitor for side effects during the use of anti-psychotic medication for another resident. This resident, diagnosed with Alzheimer's Dementia, unspecified mood disorders, and anxiety disorder, had an order for Quetiapine 25 mg at bedtime and received the medication daily. However, review of the Medication Administration Record and progress notes showed no documentation of side effect monitoring while the anti-psychotic was administered. The Director of Nursing confirmed in an interview that there was no documentation of side effect monitoring for this medication.