Failure to Implement Non-Pharmacological Interventions Prior to PRN Pain Medication
Penalty
Summary
Surveyors identified a deficiency in pain management when the facility failed to follow its Pain Assessment and Management policy, which required development and implementation of both non-pharmacological and pharmacological interventions to address pain. The care plan for Resident #53, who had diagnoses including acute osteomyelitis of the right ankle and foot and a lumbar vertebra fracture, documented that the facility would attempt non-pharmacological pain interventions as part of the treatment plan. Physician orders dated 2/11/26 and 3/20/26 authorized Hydrocodone-Acetaminophen 5-325 mg every four hours as needed. However, review of the MAR on 3/30/26 showed no documentation that non-pharmacological pain management was attempted prior to administering the PRN hydrocodone on multiple dates (3/17/26, 3/18/26, 3/20/26, 3/23/26, and 3/24/26). In an interview on 4/1/26, the CNO confirmed that non-pharmacological pain management should have been offered before administering the hydrocodone and that it had not been, resulting in the facility’s failure to provide adequate pain management for this resident. This failure created the potential for residents to experience continual pain and distress.
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