Failure to Document and Provide Non-Pharmacological Interventions Prior to PRN Pain Medication Administration
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions (NPIs) were offered, provided, and documented prior to administering as-needed pain medications for three residents. For one resident with bipolar disorder, depression, and anxiety who required substantial assistance with daily living, hydrocodone-acetaminophen was administered eight times in April without any documentation that NPIs were offered or provided, contrary to facility expectations. The Director of Nursing Services confirmed that NPIs should have been documented in the Medication Administration Record (MAR) or progress notes before giving as-needed pain medication. Another resident with severe cognitive impairment had an order for oxycodone that specifically required documentation of NPIs prior to administration, but the MAR and TAR showed multiple instances where the opioid was given without such documentation. Additionally, a resident with chronic pain, depression, diabetes, and other conditions received oxycodone 20 times in April without NPIs being provided beforehand. Staff interviews confirmed that NPIs were not documented or available for these residents as required, and that pain medication records did not meet facility expectations.