Failure to Attempt Non-Pharmacological Pain Interventions Before PRN Medication
Penalty
Summary
Facility staff failed to implement a complete pain management program for one resident who required such services. Specifically, the staff did not attempt or document non-pharmacological interventions prior to administering PRN tramadol on multiple occasions in July and August 2024. The resident had a physician's order for tramadol 50mg every six hours as needed for pain, and the medication was administered on several dates without evidence that alternative pain management strategies were tried first. A review of the resident's clinical record, including medication administration records and nurses' notes, did not show that non-pharmacological interventions were offered or attempted before giving the as-needed pain medication. Staff interviews confirmed that such interventions, including touch, relaxation, exercise, or music, should be attempted and documented prior to administering PRN pain medication. The facility's own policy also outlined various non-pharmacological approaches that may be appropriate alone or with medications, but there was no documentation that these were utilized for the resident in question.