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F0605
B

Failure to Document and Implement Nonpharmacological Interventions Prior to Administering Narcotic Pain Medications

Fullerton, California Survey Completed on 09-09-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that nonpharmacological interventions (NPIs) were consistently implemented and documented prior to administering narcotic pain medications to a resident. Medical record review showed that the resident had physician orders for NPIs such as repositioning, dim lighting, relaxation, distraction, music, and massage to be attempted before administering hydrocodone-acetaminophen or Ultracet for moderate to severe pain. Despite these orders, there was no documented evidence that NPIs were attempted before administering these medications on several occasions. Interviews with nursing staff and the Director of Nursing confirmed that NPIs should have been implemented and documented prior to giving pain medication, but the resident's medical record did not reflect this practice on the specified dates. The lack of documentation and implementation of NPIs prior to administering narcotic medications constituted a failure to prevent unnecessary medication use for the resident reviewed.

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