Failure to Provide and Document Non-Pharmacological Pain Interventions and Medication Review
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary medications by not providing or documenting non-pharmacological interventions (NPIs) for pain management, not monitoring for side effects, and not reassessing the necessity of certain medications upon admission. For one resident on hospice care with severe cognitive impairment, morphine was administered multiple times for pain and dyspnea, but there was no documentation that NPIs were attempted prior to medication administration, despite facility policy and staff expectations that NPIs should be tried and documented before giving medication. Another resident with a pelvic fracture and constant pain received both acetaminophen and morphine as needed for pain, but there was no documentation of NPIs being offered or attempted, nor was there documentation of side effect monitoring, even though these were ordered. Additionally, this resident was given omeprazole for GERD without an active diagnosis for the condition, and staff confirmed that the necessity of this medication was not reassessed upon admission. A third resident with a history of hip fracture and pain received as needed acetaminophen on multiple occasions, but again, there was no documentation that NPIs were attempted or provided. Staff interviews confirmed that NPIs should have been offered and documented, and that the lack of documentation did not meet facility expectations. The facility's own pain management policy required staff to determine and document both pharmacological and non-pharmacological interventions and to evaluate their effectiveness, which was not followed in these cases.