Failure to Specify Pain Severity in PRN Analgesic Order
Penalty
Summary
The facility failed to ensure that a licensed nurse implemented the facility's policy and procedure regarding medication orders by not specifying the severity of pain for a PRN hydrocodone-acetaminophen order for one resident. The resident, who had significant medical conditions including hemiplegia, hemiparesis, type 2 diabetes with neuropathy, and aphasia, was cognitively impaired and dependent on staff for care. The medication order for hydrocodone-acetaminophen via G-tube was written as 'every four hours as needed for pain' without indicating the pain severity (such as moderate or severe pain) or using a numerical pain scale, as required by facility policy. Record reviews and staff interviews confirmed that the medication was administered for pain levels ranging from 4 to 9, but the original order did not specify the pain level threshold for administration. Both nursing staff and the Director of Nursing acknowledged that the order should have been clarified with the physician to specify the appropriate pain level for administration. Facility policies required PRN orders to specify the condition for use and for staff to clarify incomplete orders, but this was not followed in this instance.