F0697

E

Failure to Use Non-Pharmacological Interventions Before PRN Pain Medication

Yardley, Pennsylvania Survey Completed on 02-27-2026

Penalty

No penalty information released

Summary

The facility failed to follow its pain management policy and the resident’s care plan by not attempting or documenting non-pharmacological pain interventions before administering PRN pain medication to one resident. Facility policy, last reviewed January 25, 2026, required that physicians order both non-pharmacological and medication interventions for pain, and that staff provide a comfortable environment and complementary measures such as local heat or ice, repositioning, massage, and opportunities to talk about chronic pain. Resident 13, who had dementia, diabetes, and abnormalities of gait and mobility, had a physician’s order dated November 26, 2025, for tramadol every 12 hours as needed for pain, and a care plan that directed staff to use positioning, relaxation therapy, heat, cold application, bathing, and/or muscle stimulation for pain relief. Medication Administration Records showed that staff administered PRN tramadol without documented evidence that non-pharmacological interventions were attempted beforehand on 15 occasions in December 2025, 13 occasions in January 2026, and 18 occasions in February 2026. In an interview, the Assistant Director of Nursing confirmed there was no evidence that non-pharmacological pain interventions were provided prior to administering the PRN pain medication as required.