F0757

D

Failure to Document Indications and Non-Pharmacological Interventions Before PRN Opioid Use

Minneapolis, Minnesota Survey Completed on 01-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure residents’ drug regimens were free from unnecessary drugs by not identifying clear indications for opioid use and not documenting attempts or offers of non-pharmacological interventions prior to administering PRN pain medications. For Resident 1 (R1), the admission MDS showed intact cognition and diagnoses including end stage renal disease and a heel pressure ulcer, with a pain assessment indicating pain frequently interfered with therapy and daily activities. R1’s care plan for chronic neuropathic pain directed staff to offer non-pharmacological interventions such as rest and repositioning and to observe and document pain characteristics. Despite this, documentation showed that when R1 received PRN acetaminophen and hydromorphone, the associated progress notes consistently lacked details on pain location, associated symptoms, and whether any non-pharmacological interventions were attempted or offered before medication administration.

R1 had PRN orders for both acetaminophen and hydromorphone. In January, R1 received PRN acetaminophen twice and PRN hydromorphone nine times. For the PRN acetaminophen doses, one note documented severe pain rated 8/10 and another documented moderate foot pain rated 5/10, but neither note included any record of non-pharmacological interventions being attempted or offered prior to giving the medication. For the PRN hydromorphone doses, pain ratings ranged from 0/10 to 9/10, yet the corresponding progress notes repeatedly only stated that the medication was administered and effective, without documenting pain location, symptoms, or any non-pharmacological measures tried beforehand. In one instance, hydromorphone was administered when the pain rating was documented as 0/10. During interview, R1 reported chronic pain in the knees and all over the body and stated that repositioning, ice packs, and rest helped relieve pain in addition to PRN medications, indicating that non-pharmacological measures were known to be helpful but were not reflected in the documentation.

For Resident 2 (R2), the admission MDS indicated independent decision-making with diagnoses including amputation and end stage renal disease, and a pain assessment showing pain frequently interfered with day-to-day activities. R2’s care plan for pain management included an intervention to offer non-pharmacological measures and to notify the practitioner if these were unsuccessful or if the pain complaint represented a significant change. R2 had PRN orders for acetaminophen and oxycodone. In January, R2 received PRN acetaminophen twice for pain rated 10/10 and PRN oxycodone five times for pain rated between 5/10 and 7/10. The associated progress notes documented that medications were administered and, in some cases, that the resident felt better, but did not include pain location, associated symptoms, or any record of non-pharmacological interventions being attempted or offered prior to either non-opioid or opioid administration. During interview, R2 stated that pain sometimes occurred at the amputation site, in both arms, and all over the body when tired, and that repositioning, ice packs, and rest helped relieve pain along with PRN medications, again contrasting with the lack of documentation of such measures.

Interviews with staff and facility leadership further highlighted the deficiency. An LPN stated that when a resident had pain, the nurse should ask about pain location and intensity, administer the requested PRN medication if multiple options were available, and document the time and pain level, with follow-up to reassess effectiveness. An RN stated that non-opioid medications should be offered first for pain less than 7/10 and opioids for pain rated 7–10/10, and that residents requesting opioids would be educated but ultimately given the requested medication, with documentation of administration and pain level and later follow-up. The DON stated that documentation for PRN pain medications should include pain location, pain scale rating, and any non-pharmacological interventions attempted prior to administration so that pain follow-up and trending could be done accurately. The nurse practitioner and pharmacist both indicated that non-opioid medications should be used first and that opioids are generally reserved for more severe pain, and the facility’s Pain Management Program policy required clear documentation of pain evaluation, interventions (including non-pharmacological measures), and post-administration pain relief. Despite these stated expectations and policies, the records for R1 and R2 showed repeated administration of PRN opioids and non-opioids without documented indication details or non-pharmacological interventions, constituting the cited deficiency.