Failure to Provide Non-Pharmacological Interventions and Assessment Prior to PRN Pain Medication
Penalty
Summary
The facility failed to ensure that a resident was provided with non-pharmacological interventions and a proper assessment prior to administering as-needed pain medication. According to facility policy, all residents should be screened and assessed for pain, with documentation of interventions and responses, especially for those who are cognitively impaired or unable to communicate effectively. In this case, a resident with diagnoses including anxiety, Alzheimer's disease, and high blood pressure, who was unable to verbalize pain, was administered PRN acetaminophen for a reported pain level of 7/10. The clinical record did not show evidence that a physical assessment or vital signs were obtained prior to the administration, nor that non-pharmacological interventions were attempted or documented before giving the medication. Further review of the resident's clinical record revealed that after the administration of acetaminophen, the resident's pain was reassessed and found to be zero. However, later that same day, the resident exhibited a significant change in condition, including a low rectal temperature, bradycardia, hypotension, and unresponsiveness. The nurse notified the family and the resident was sent to the emergency room, where they were admitted for altered mental status and a urinary tract infection. Staff interviews confirmed that the required assessments and documentation of non-pharmacological interventions were not completed prior to administering the PRN medication. Staff interviews also indicated that the resident typically exhibited behaviors such as yelling out and clenching fists, which were used as non-verbal indicators of pain. However, the LPN responsible for administering the medication could not recall if non-pharmacological interventions were implemented or documented prior to giving the acetaminophen. The DON confirmed that the facility did not ensure the resident received non-pharmacological interventions and an assessment before administering pain medication as required by facility policy and state regulations.