Failure to Implement and Document Non-Pharmacological Pain Interventions Prior to Analgesic Use
Penalty
Summary
The deficiency involves the facility’s failure to provide and document non-pharmacological pain interventions prior to administering PRN and scheduled pain medications for three residents. Facility policy titled “Pain Recognition and Management” (revised 4/2025) required staff to manage or prevent pain consistent with the comprehensive assessment and care plan, including both pharmacological and non-pharmacological interventions based on resident needs, preferences, and goals. For each of the three residents, physician orders included specific non-pharmacological pain interventions such as repositioning, dim light/quiet environment, relaxation, distraction, music, and massage to be used as needed. For one resident with moderate cognitive impairment, physician orders included scheduled and PRN tramadol for pain, as well as PRN acetaminophen for mild and moderate pain, along with ordered non-pharmacological interventions. Medication administration records for November, December, and January showed multiple administrations of tramadol and acetaminophen; however, the medical record contained no documented evidence that any of the ordered non-pharmacological interventions were provided prior to giving these pain medications. The DON later verified these findings during record review. For a second resident who could make her own medical needs known and reported intermittent abdominal and lower back pain, physician orders included PRN acetaminophen for mild and moderate pain, PRN hydrocodone-acetaminophen for severe pain, and the same set of non-pharmacological interventions. MARs for December, January, and February showed repeated administrations of acetaminophen and hydrocodone-acetaminophen, but the medical record lacked documentation that non-pharmacological interventions were implemented before medication administration. A third resident, with fluctuating capacity but able to make needs known, had multiple sequential PRN Percocet orders for severe pain and corresponding non-pharmacological pain orders. MARs for January and February documented frequent Percocet administration, yet there was no documented evidence that non-pharmacological interventions were provided prior to these doses. LVN 7 stated that non-pharmacological interventions should be used before pain medications and confirmed that such interventions were not provided before administering pain medications to two of the residents, and the DON acknowledged the lack of documentation for all three residents.
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