Failure to Document Non-Pharmacological Pain Interventions Prior to PRN Medication Administration
Penalty
Summary
Facility staff failed to implement a complete pain management program for one resident who was cognitively intact and had a physician's order for prn (as needed) Percocet for pain. The clinical record and electronic medication administration record (eMAR) showed that the resident received Percocet on multiple occasions, but there was no documentation that non-pharmacological interventions were attempted prior to administering the medication on at least two of those dates. Progress notes and the eMAR lacked evidence of such interventions, despite facility policy requiring evaluation and documentation of non-pharmacological pain management methods before administering prn pain medication. During staff interviews, an LPN confirmed that the standard procedure is to assess the resident, attempt non-pharmacological interventions, and only administer prn pain medication if those interventions are ineffective. The LPN also acknowledged that there was no documentation of non-pharmacological interventions for the resident on the specified dates. The facility's policy further supports the requirement to monitor and document the effectiveness of non-pharmacological interventions as part of pain management.