|§483.45(d) Unnecessary Drugs-General. |
Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-
§483.45(d)(1) In excessive dose (including duplicate drug therapy); or
§483.45(d)(2) For excessive duration; or
§483.45(d)(3) Without adequate monitoring; or
§483.45(d)(4) Without adequate indications for its use; or
§483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or
§483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section.
Based on clinical record review, facility policy, and staff interview, it was determined that the facility failed to provide non-pharmacological interventions and to accurately assess pain levels prior to the administration of pain medication to determine adequate indications of use for one of five residents (Resident #5)
Review of facility policy, titled "Pain Monitoring and Management" written February 2017 revealed Number 4. "If resident is having pain, provide non-pharmacological interventions (i.e.: repositioning, cold compress) and document effectiveness of those interventions. Number 5. revealed "If the non-pharmacological interventions are not effective in reducing the pain to an acceptable level, administer pain medications as ordered.
Continued review of facility policy titled, "Pain Monitoring and Management" identified pain scale as follows: 0= No Pain; 1-3=Mild Pain; 4-6= Moderate Pain; 7-9= Severe Pain; and 10=Excruciating Pain. "If the resident states that the pain is a level 10, excruciating pain, notify the physician."
Review of Resident #5's clinical record revealed diagnoses including but not limited to Fistula of Intestine (abnormal opening in your digestive tract that causes gastric fluids to seep through the lining of your stomach or intestines, resulting in infection when the fluids leak into skin or other organs); Chronic Obstructive Pulmonary Disease (disease process that causes decreased ability of the lungs to perform); Degenerative Disc Disease (symptoms of back or neck pain caused by wear-and-tear on a spinal disc); Gout (type of arthritis that causes inflammation of joints due to excess uric acid causing intense pain) and Osteoarthritis (pain and stiffness in the joints, swelling, warm and tender joints and limited movement of affected joints).
Review of Resident #5's MDS (Minimum Data Set -periodic assessment of resident needs) dated November 20, 2018 revealed in Section C: Cognitive Patterns; subsection C500 BIMS (Brief Interview of Mental Status) score of 7 out of 15 which indicated a moderate severity of cognitive deficits.
Review of Resident #5's June 2018 physician's orders revealed an order for Tramadol (pain reliever medication that is used to treat moderate to severe pain in adults) 50mg (milligrams) with administration instructions: Give 1 tablet by mouth every 6 hours as needed for severe pain.
Review of Resident #5's June 2018 MAR (Medication Administration Record) revealed Tramadol 50 mg was administered on June 20, 2018 for a pain rating of "6"; June 27, 2018 for a pain rating of "1"; and June 28, 2018 for a pain rating of "5".
Further review of Resident #5's June 2018 MAR revealed Tramadol 50mg was administered on June 27, 2018 at 9:14 a.m. without a pain scale obtained prior to the pain medication administration.
Review of Resident #5's November 2018 physician's orders revealed an order for Tylenol 325 mg (pain reliever medication used to treat pain or fever) with administration instructions: give 2 tablets by mouth every 4 hours as needed for mild pain.
Review of Resident #5's November 2018 MAR revealed Tylenol 325 mg was administered on November 8, 2018 three times for a pain rating of "5"; November 13, 2018 for a pain rating of "5," and on November 17, 2018 for a pain rating of "8".
Review of Resident #5's December 2018 MARs revealed Tylenol 325 mg was administered ten times for a pain rating of "5" on December 5, 16, 18, 19, 21, 24, 26, 27, 29, and December 30, 2018.
Review of Resident #5's clinical record including but not limited to MARs, progress notes, care plans, and assessments failed to reveal non-pharmacological interventions were attempted prior to the administration of the pain medications in June (June 27 and 28), November, and December of 2018.
Interview on February 26, 2019 at approximately 10:55 a.m. with the Director of Nursing confirmed that the pain medications were administered to Resident #5.
28 Pa. Code 211.5(f) Clinical Records,
Previously cited 03/19/18
28 Pa. Code 211.12(d)(5) Nursing Services
Previously cited on 03/19/18
| ||Plan of Correction - To be completed: 04/05/2019|
Resident #5's clinical record was reviewed specifically pain record and updated to include non-pharmacological interventions prior to the administration of pain medication. These non-pharmacological interventions are recorded in Resident #5's medication administration record.
Resident #5's record was updated to include pain scale to quantify mild, moderate or severe pain consistent with our pain management policy. Physician orders were obtained to specify dosing of prescribed pain medication based on severity of pain indicated on pain scale as reported by resident.
Resident #5's record reflects that prior to the administration of pain medication including but not limited to the use of Tylenol and Tramadol reflects the assessment of pain prior to the administration as well as following the dosing guidelines established to indicate mild, moderate or severe pain and the offer of non-pharmacological interventions.
Clinical records reviewed for all residents with prescribed pain medication. Update made to resident records to include quantification of pain scale to indicate mild, moderate or severe pain to mirror pain management policy and offering dosing consistent with physician orders. Based on resident pain assessment licensed staff will also offer and document non-pharmacological interventions prior to the administration of pain medication.
Facility pain management policy has been reviewed and all residents with prescribed pain medication will include quantified pain scale, dosing specifications per physician orders to mirror pain scale reflected in pain management policy as well as the offer and documentation of non-pharmacological interventions prior to the administration of any pain medication.
Random audits will be performed by Director of Nursing or designee of resident records that include prescribed pain medication to ensure that pain assessments are completed, non-pharmacological interventions are offered , pain medication orders include quantified pain scale to specify mild, moderate or severe pain as well as dosing guidelines for assessed pain per physician orders. Random audits will be completed by April 5th 2019 and will be reported quarterly through Quality Assurance committee as appropriate.
Education will be provided to all licensed staff regarding adherence to facility pain management policy to include pain assessment, offering and documenting non-pharmacological interventions, inclusion of quantified pain scale to specify mild, moderate and severe pain for all pain medication and following of dosing guidelines set per physician's orders.