Failure to Implement Physician's Orders for Pain Management
Penalty
Summary
The facility failed to implement the physician's orders for pain management for one resident following a left hip hemiarthroplasty. The resident had a history of left femur fracture, generalized anxiety disorder, and polyneuropathy, and was admitted for aftercare following joint replacement surgery. Physician orders required staff to document non-pharmacological interventions for pain, such as heat, repositioning, relaxation breathing, food/fluid, massage, exercise, and immobilization, and to document the results. The orders also specified that Tramadol 50 mg could be administered every six hours as needed for moderate to severe pain rated 5 to 10 out of 10. The resident's care plan and physician orders further required pain monitoring every shift and documentation of non-pharmacological interventions and their results. Record review revealed that the resident experienced moderate pain on several occasions, but there was no documentation that non-pharmacological interventions were offered or provided as required by the physician's orders. Additionally, the Medication Administration Record (MAR) showed that the resident received Tramadol on multiple occasions when reporting 0/10 pain, which did not meet the prescribed parameters. Interviews with nursing staff confirmed that non-pharmacological interventions were not consistently offered or documented, and that pain medication was administered outside of the physician's order parameters. Further interviews with the resident and medical staff corroborated that non-pharmacological pain management interventions were not offered when the resident reported pain and discomfort. The facility's policies required documentation of non-pharmacological interventions and administration of medications in accordance with prescriber orders, but these were not followed. The deficiency was identified through review of records, interviews with staff and the resident, and examination of facility policies.