Failure to Administer PRN Pain Medications Within Ordered Pain Parameters
Penalty
Summary
The deficiency involves the facility’s failure to ensure that PRN pain medications were administered within the physician-ordered pain scale parameters for three residents. For one resident with type 2 diabetes, dysphagia, dementia, acute kidney failure, and a cognitive communication deficit, the MDS showed she was cognitively intact and receiving antidepressant and opioid medications. Pharmacy review in December 2025 specifically requested that nursing staff be reminded that pain medications must be given within parameters. Despite this, review of the MARs showed acetaminophen and tramadol were repeatedly administered outside the ordered pain scale ranges across multiple months, including June, November, December, January, and February. Another cognitively intact resident with aftercare following joint replacement surgery, dysphagia, cognitive communication deficit, and acute kidney failure had an order for acetaminophen 325 mg, two tablets every six hours PRN for generalized or breakthrough pain rated 1–4. The February MAR showed acetaminophen was administered outside of these parameters on three separate dates. This resident’s care plan, initiated in September 2025, identified a need for pain management related to right hip pain and included an intervention to administer analgesia per physician’s orders, yet the MAR documentation demonstrated that the ordered parameters were not consistently followed. A third cognitively intact resident with encephalopathy, acute and chronic respiratory failure, and acute kidney failure had an order for oxycodone 10 mg every four hours PRN for pain rated 6–10. The February MAR showed oxycodone was administered once when the resident rated pain as 3, which was outside the ordered parameters. During interviews, an LPN, the ADON, and the interim DON each reviewed the MARs and acknowledged that acetaminophen, tramadol, and oxycodone had been administered outside the prescribed pain parameters, and they described risks such as overdose, unnecessary sedation, over-sedation, lethargy, respiratory distress, constipation, and residents not being able to get ahead of their pain. Review of the facility’s undated Medication Administration policy showed it did not contain language about administering medications according to physician-established pain parameters, although it did reference reviewing the MAR for special considerations and conducting three checks against the physician’s order, pharmacy label, and MAR.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.