Failure to Ensure Drug Regimen Free from Unnecessary Opioids
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs, specifically regarding the use of opioids. The resident in question had multiple complex diagnoses, including nontraumatic subarachnoid hemorrhage, intracerebral hemorrhage, dysphagia, aphasia, epilepsy, COPD, chronic respiratory failure, and diabetes. Despite these conditions, documentation showed that the resident was regularly administered oxycodone, an opioid, without consistent evidence of pain assessments or attempts at non-pharmacological interventions prior to administration, as required by facility policy and the resident’s care plan. Review of the Medication Administration Record (MAR) over several months revealed that oxycodone was given on numerous occasions when pain assessments were either not documented or marked as 'NA' (not applicable), and non-pharmacological interventions were not attempted or recorded before opioid administration. In many instances, the overall pain rating for the shift was documented as zero, and there was no indication that the resident experienced moderate to severe pain or requested the opioid. Additionally, acetaminophen, a non-opioid analgesic, was not administered prior to oxycodone, and documentation of non-pharmacological interventions was largely absent. Interviews with the resident and multiple CNAs indicated that the resident’s discomfort was typically related to personal care activities and subsided once care was completed, with the resident preferring non-pharmacological interventions such as staff taking their time and following her instructions. The DON confirmed that 'NA' was not an approved method for documenting pain assessments and acknowledged the lack of consistent pain assessments and intervention documentation prior to opioid administration. Facility policy required exploration and documentation of both pharmacological and non-pharmacological interventions for pain, which was not followed in this case.