Deficiency in Pain Pump Management for Resident
Summary
The facility failed to ensure that licensed nurses had the necessary knowledge, competencies, and skill sets to provide care for a resident with an intrathecal pain pump. Prior to admission, the facility did not assess whether the nursing staff could meet the needs of the resident, who was a quadriplegic with chronic pain and at risk for Autonomic Dysreflexia. The resident required specialized care due to a surgically implanted pain pump that delivered medication directly to the spinal cord. The facility did not provide adequate training or assess the nursing staff's performance in managing the resident's pain pump, leading to a lack of proper pain management. The resident, who was cognitively intact, was admitted with several medical conditions, including neuromuscular dysfunction of the bladder, osteoporosis, quadriplegia, and stage 4 pressure ulcers. Despite the resident's complex medical needs, the facility's staff were not informed or trained on how to manage the pain pump. The resident reported experiencing unmanaged pain and requested assistance with the bolus dose from the pain pump, but the nursing staff were unfamiliar with the device and did not provide the necessary support. The facility's PCP was also unaware of the pain pump's functionality and offered alternative oral pain medications, which the resident declined due to concerns about potential overdose. Interviews with the nursing staff revealed that they were not trained or experienced in handling pain pumps, and the facility's DON admitted to not knowing about the resident's pain pump prior to admission. The facility's failure to assess and ensure the competency of its nursing staff in managing the resident's pain pump resulted in inadequate pain management and placed the resident at risk for serious complications. The facility's policies and procedures did not adequately address the specific needs of residents with implanted pain pumps, leading to a deficiency in care.
Removal Plan
- Resident #1 was assessed for signs and symptoms of pain by the Licensed Nurse - her pain level was a 6. After medication administration, pain level assessed as effective.
- Order for prn bolus is every 6 hours was entered in the PCC orders.
- Self-Administration of meds was completed for resident involved.
- Pain care plan was updated by DON/ designee. Included signs and symptoms of medication side effects, pain medication therapy, chronic pain, pain pump management.
- No other residents in the center have a pain pump.
- All residents have been evaluated for pain. All residents' pain needs are being met. No other residents were identified as affected by failure to manage residents' pain.
- Director of Nursing or designee educated the licensed nurses on the following educational components: Pain Management includes evaluation of pain and administering medication as ordered by the attending physician.
- If a medication is unavailable and you can obtain from E-Kit.
- Nursing staff training on use of implanted pain pump use.
- Completion of the self-administration of medication evaluation.
- The regional clinical specialist educated the director of nursing and admissions director for reviewing preadmission screening and admission documents as much as they are available prior to admission.
- All Licensed Nurses will be educated by the Director of Nursing and/ or designee prior to working their next shift. Education will continue until all Licensed Nurses have completed the required education. The Licensed Nurses that are PRN (as needed) and/or out on FMLA/LOA will have the education completed prior to working their next scheduled shift before providing care to residents. Newly hired Licensed Nurses will receive this training during orientation prior to providing care to the residents.
- Director of Nursing educated by the regional clinical specialist. Administrator educated by the regional clinical specialist. The training will include the above-stated educational components.
- The Director of Nursing and/ or designee will review new admissions in the morning clinical meeting to review new admission and reconcile new admission orders. Education provided by the regional clinical specialist.
- An Ad Hoc QAPI meeting was held with the Medical Director, facility Administrator, Director of Nursing, and Regional Clinical Specialist to review the IJ Template and the Plan for Removal.
- The Director of Nursing/ designee will review new admissions for residents that may have implanted pain pumps to ensure necessary assessment, orders, notifications, and care plans are implemented.
- The Director of Nursing will monitor to ensure the process is in place daily (Monday-Friday) for three months, and the weekend supervisor on Saturday and Sunday. Education provided by regional clinical specialist. Trends will be presented and discussed in the monthly QAPI meeting for three months.
- The administrator will ensure that the director of nursing and the admissions coordinator are reviewing preadmission screening and admission documents prior to admission to ensure that medication orders / equipment / DME are available upon admission for resident condition.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Insulin Pen Priming Competency Not Verified: An LPN administered Humalog insulin to a resident without priming the Kwik Pen first and stated she was unaware that priming was required. The facility could not produce the nurse's skills check sheet, and the competency form reviewed did not include priming an insulin pen, despite the insulin instructions stating the pen must be primed before each injection.
A facility failed to ensure a QMA had a current license while distributing meds to residents. Record review showed the QMA was scheduled and worked on multiple days across 3 resident units, but the licensure binder and Indiana License Registry showed the QMA's license had expired. The ED stated staff should not distribute meds with an expired QMA license and that the facility had no written policy requiring QMAs to work with a current license.
Missing Mandatory Orientation and Training for Agency CNA: The facility assigned an agency CNA to provide resident care without documentation showing completion of required orientation and in-service training. The CNA stated they did not receive orientation, a training packet, or training on abuse/neglect, dementia care, behavioral health, trauma-informed care, or managing difficult behaviors before working on resident units. The ADON/Staff Educator and DON stated the required training should have been completed and documented in the employee file, but the records could not be located.
CNA Competency Review Completed After Annual Evaluation: The facility failed to ensure that a CNA received a comprehensive clinical competency skills review before the CNA's annual performance evaluation. Record review showed the CNA's annual performance review was completed before the competency review, and the DSD stated she was unaware of the requirement that the skills competency evaluation be completed prior to the annual evaluation.
Incompetent PEG Tube Medication Administration: An LPN was observed administering crushed medication via a resident’s PEG tube but poured the diluted medication directly into the tube without a syringe, causing it to spill. The LPN then did not know how to connect the syringe to the PEG tube and had to call for help, while the DON provided instruction. The resident had diagnoses including an unstageable sacral pressure ulcer, pain, and aphasia following cerebral infarction, and the DON stated the resident did not receive the full dose of medication.
A resident with urinary retention and BPH required a coude catheter, but when the catheter became obstructed, an LPN told the resident to wait until day shift for a change and did not notify the RN supervisor or seek help. Facility records showed no competency training, return demonstration, or skills validation for Foley or coude catheter care, and multiple nurses said they had not received facility-specific education or competency checks for coude catheter management.
Insulin Pen Priming Competency Not Verified
Penalty
Summary
The facility failed to ensure staff possessed the skills and competencies required when a Licensed Nurse administered Humalog insulin to R19 without priming the Kwik Pen first. On 06/02/2026 at 10:13 AM, R19 walked in the hall with a walker, then went to her room with the nurse to receive insulin. The nurse clicked up seven units in the pen and administered the insulin in R19's left arm without priming the pen, and then verified that she had not primed it and stated she was unaware she was supposed to. When the facility was asked for the nurse's skills check sheet, it could not provide it. Review of a blank medication pass competency check sheet showed no competency assessment for priming an insulin Kwik Pen. The insulin pen instructions in the pamphlet directed staff to prime the pen before each injection, and Administrative Nurse D stated she expected staff to prime the insulin pen with two units before administration. She also stated that nurses were required to complete an insulin competency check-off upon hire, and later verified that the nursing skills check lacked a competency item for priming an insulin Kwik Pen.
Expired QMA License During Medication Distribution
Penalty
Summary
The facility failed to ensure that a Qualified Medical Assistant had a current license while distributing medications to residents. A record review showed that QMA 3 was scheduled to distribute medications and had worked as a QMA on multiple days across three resident units from April through the review period. The facility's Employee Certification and Licensure binder showed that QMA 3's license had expired, and the Indiana License Registry website also indicated the license was expired. In interviews, the Executive Director stated that staff should not distribute medications with an expired QMA license and that the facility did not have a written policy requiring QMAs to work with a current license.
Missing Mandatory Orientation and Training for Agency CNA
Penalty
Summary
Certified Nurse Aide #1 was assigned resident care duties on 05/11/2026 as agency staff, but the facility could not provide documentation showing completion of required orientation and mandatory training before the aide worked independently. The missing documentation included, but was not limited to, Abuse/Neglect/Exploitation Prohibition, Behavioral Care Services/Cognitive Impairment/Dementia Training, Trauma Informed Care, Communication Training, and other required orientation and in-service training elements. During the survey, the Assistant Director of Nursing/Staff Educator stated agency staff are required to complete the same mandatory orientation and in-service training as facility staff and that training modules, sign-off documentation, and post-tests are maintained in employee files. However, the facility was unable to locate records verifying that Certified Nurse Aide #1 completed the required training. Certified Nurse Aide #1 stated they did not receive orientation, a training packet, or any of the listed training topics before being assigned to provide resident care on Units 2 and 3. The Administrator also stated that all staff are required to complete mandatory orientation and in-service training prior to working independently and that documentation should have been maintained in the employee file.
CNA Competency Review Completed After Annual Evaluation
Penalty
Summary
The facility failed to implement its policy regarding nursing staff competency by not ensuring that CNA 3 received a comprehensive clinical competency skills review before the CNA's annual performance evaluation. During a concurrent interview and record review on 5/29/2026 at 12:18 p.m., the Director of Staff Development reviewed CNA 3's personnel file, the C.N.A. Comprehensive Clinical Competency Review- Skills Checklist form, and the Annual Performance Review form. The review showed that CNA 3's clinical competency review was completed on 1/22/2026, while the annual performance evaluation was completed earlier, on 12/24/2025. During a concurrent interview and record review on 5/29/2026 at 12:26 p.m., the Director of Staff Development reviewed the facility's policy titled Nursing Staffing Competency and stated she was unaware of the facility's requirement that the annual skills competency evaluation be completed prior to a CNA's annual performance evaluation. The policy stated that the facility will identify annual skills competencies needed for each role and establish a schedule or process to facilitate completion of skills and competency evaluations, and that successfully completed orientation and skills check are required prior to the employee's annual evaluation.
Incompetent PEG Tube Medication Administration
Penalty
Summary
The facility failed to ensure licensed nurses had the necessary competency skills to administer medication via PEG tube for one resident. During an observed medication pass, an LPN prepared crushed medication for the resident’s PEG tube, donned a gown and gloves, stopped the tube feeding, and checked placement and residual. The LPN then poured water and the crushed medication into a 30 ml cup and attempted to pour the diluted medication directly into the PEG tube without using a syringe, causing the medication to spill out over and around the tube. The LPN then obtained another cup with diluted medication and a syringe but did not know how to connect the syringe to the PEG tube, hesitated, activated the call light, and stated they would call for assistance. The DON later entered the room and provided instructional assistance to the LPN on administering medication through the PEG tube. The resident had diagnoses including an unstageable sacral pressure ulcer, pain, and aphasia following cerebral infarction. A physician order directed flushing the PEG tube with 30 ml of water before and after medications and 15 ml between each medication. The LPN stated they were unsure how much medication the resident received when the diluted medication spilled during administration. The DON stated the LPN did not correctly administer the medication via the PEG tube, that the medication was spilled and the resident did not receive the full dose, and that the LPN should have notified the physician. The DON also stated the facility used skills competency checklists upon hire and yearly during a skills fair, but the LPN did not have a skills competency checklist completed upon hire and was past the 90-day timeframe for completion.
Lack of competency validation for coude catheter care
Penalty
Summary
The facility failed to ensure licensed nursing staff possessed and demonstrated the competencies needed to safely assess, manage, and provide care for residents requiring a coude catheter. Resident 9 was admitted with urinary retention and benign prostatic hyperplasia with lower urinary tract symptoms, and a care plan dated March 30, 2026, identified the need for a coude catheter. On May 7, 2026, nurse documentation and interview with the DON showed the resident’s coude catheter became obstructed during the night shift, and the LPN on duty told the resident he would need to wait until day shift staff arrived for the catheter to be changed. The DON stated the LPN reported she was not comfortable changing the coude catheter because of a lack of familiarity and experience with that type of catheter, and she did not notify the RN supervisor or seek assistance to ensure timely catheter intervention. Review of facility documentation titled Skilled Nursing Competency Training showed competencies listed for licensed practical nurses, including nephrostomy tubes and suprapubic catheters, but the facility did not include competency training, return demonstration, or skills validation for Foley catheter insertion, Foley catheter management, or coude catheter care and replacement. During interviews, four licensed nurses stated they had general catheter education in nursing school and prior experience with coude catheters at previous employers, but all reported the facility had not provided facility-specific education, training, competency evaluation, or skills validation related to coude catheter care, evaluation, insertion, replacement, or management. The DON was unable to provide documented evidence that licensed nursing staff had completed education, training, competency evaluations, or demonstrated proficiency for Foley catheter care or specialized coude catheter management.
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