Failure to Document Non-Pharmacological Pain Interventions Prior to PRN Narcotic Administration
Penalty
Summary
The facility failed to ensure that pain management for a resident with chronic pain and other significant medical conditions was consistent with professional standards. Clinical record review showed that the resident, who had diagnoses including pneumonia due to pseudomonas, chronic pain, and chronic respiratory failure with hypoxia, had a physician's order for Oxycodone HCl to be given as needed for severe pain. The resident's care plan included interventions for staff to identify and address factors that may enhance pain and to provide relief as able. However, review of the Medication Administration Records indicated that the resident received as needed Oxycodone HCl on multiple occasions without documented evidence that non-pharmacological interventions were attempted prior to administration. This was confirmed by the Assistant Director of Nursing, who was unable to provide documentation supporting the use of non-pharmacological pain interventions before administering the medication.