Failure to Provide and Document Non-Pharmacological Interventions Prior to Pain Medication Administration
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary medications by not providing or documenting non-pharmacological interventions (NPIs) prior to administering as needed pain medications for two residents. One resident, who had a history of falls, a humerus fracture, and chronic pain, was able to communicate needs and was administered oxycodone two to three times daily over a three-week period without any documentation of NPIs being attempted before medication administration. Staff interviews confirmed that it was the facility's expectation to attempt and document NPIs prior to giving as needed pain medication, but this was not done, and there were no orders for NPIs for this resident. Another resident, who was severely cognitively impaired, had orders for both scheduled and as needed oxycodone-acetaminophen. Review of medication administration records showed no NPIs were ordered or documented, and there was no monitoring for adverse side effects related to the pain medication. Additionally, the resident received 23 administrations of scheduled oxycodone with a documented pain score of zero, and there was no evidence that the provider was contacted regarding the continued use of pain medication despite the absence of reported pain. Staff confirmed that these practices did not meet facility expectations.