Failure to Follow Pain Management Protocols and Physician Orders
Penalty
Summary
The facility failed to develop and implement individualized pain management programs consistent with professional standards of practice for two residents. Clinical record reviews revealed that staff did not attempt non-pharmacological interventions prior to administering as-needed pain medications, despite explicit physician orders requiring such interventions. Additionally, staff repeatedly administered pain medications outside of the prescribed pain scale parameters and did not document clinical reasoning for these deviations. For one resident with diagnoses including spinal stenosis and an open wound, physician orders specified the use of acetaminophen for mild pain and tramadol for moderate to severe pain, with clear instructions to attempt non-pharmacological interventions before medication administration. However, documentation showed that tramadol was administered multiple times for pain ratings below the ordered threshold, and non-pharmacological interventions were not attempted or documented. There were also instances where the incorrect dose of tramadol was given, and acetaminophen was not administered as ordered during certain periods. Another resident with chronic obstructive pulmonary disorder and muscle weakness had an order for hydrocodone/acetaminophen to be given for pain rated 1-5. Despite this, the medication was administered on numerous occasions for pain ratings above the ordered range, with over 40 instances documented outside the provider's parameters. There was no documentation explaining the clinical reasoning for these actions. Interviews with the DON confirmed the findings related to the failure to follow physician orders, lack of non-pharmacological interventions, and inconsistency with professional standards of pain management.