Failure to Offer and Document Non-Pharmacological Interventions Before PRN Pain Medications
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess pain and to offer or attempt non-pharmacological pain interventions prior to administering PRN pain medications for two residents. One resident had severely impaired cognition, cellulitis of the right leg, type 2 diabetes, and chronic pain syndrome, with an admission MDS indicating frequent pain that interfered with day-to-day activities and use of both scheduled and PRN pain medications. This resident’s care plan included multiple non-pharmacological pain interventions such as ice, heated blankets, massage, repositioning, music, essential oils, food/drink, and relaxation breathing. Despite this, the MAR and corresponding progress notes for multiple PRN administrations of acetaminophen and oxycodone in January did not document any non-pharmacological interventions being attempted or offered prior to medication administration. The second resident had intact cognition, a stage 3 pressure ulcer, COPD, and chronic pain, with a quarterly MDS indicating almost constant pain and use of scheduled and PRN pain medications. This resident’s care plan identified a focus on pain risk related to generalized chronic pain and lower back pain, with interventions that included offering non-pharmacological pain relief prior to pain medication administration, listing the same types of non-pharmacological options as for the first resident. However, the MAR for January showed several PRN oxycodone administrations, and the associated progress notes documented that the medication was given and effective but did not include any record of non-pharmacological interventions being offered or attempted beforehand. Interviews with both residents confirmed that they experienced ongoing pain and used PRN pain medications, and each reported that repositioning sometimes helped relieve their pain. Interviews with LPN staff, the NP, and the DON established that facility practice and expectations were that non-pharmacological interventions should be offered prior to PRN pain medication administration and that such offers and any refusals should be documented in the PRN medication administration note or progress note. The DON confirmed that the medical records for the two residents did not contain documentation of non-pharmacological interventions being offered or refused prior to every PRN pain medication administration. The facility’s Pain Assessment and Management policy stated that pain management is based on appropriate assessment and treatment, including the use of non-pharmacological interventions alone or with medications, and provided examples of environmental, physical, exercise, and cognitive/behavioral interventions, which were not consistently reflected in the documentation for these residents.
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