Failure in Pain Management for Resident with Acute Pelvic Fracture
Summary
The facility failed to provide appropriate pain management for a resident who required such services, as evidenced by the events surrounding a resident with severe impaired cognition and a history of osteopenia and prior falls. On the morning of the incident, the resident reported pain and an inability to stand to a Certified Nursing Assistant (CNA). Despite this, the resident was transferred by a Licensed Practical Nurse (LPN) and the CNA before being assessed by a Registered Nurse Supervisor or receiving any pain medication. This transfer occurred prior to any documented pain assessment or administration of pain relief, which was contrary to the facility's policy requiring pain assessment by a Registered Nurse using a Pain Assessment Tool. The resident was later transferred to the hospital, where they were diagnosed with an acute pelvic fracture. The facility's investigation revealed that the resident had a history of osteopenia and previous fractures, which increased their risk for further fractures. However, there was no documented evidence of a pain assessment or administration of pain medication before the hospital transfer. The LPN claimed to have administered pain medication but failed to document it, and the Registered Nurse Supervisor only assessed the resident after they had been moved to a chair. Interviews with the staff involved revealed a lack of adherence to the facility's pain management policy. The CNA and LPN transferred the resident without a prior assessment, and the LPN did not check the resident's hip due to the resident wearing pants. The Director of Nursing acknowledged that the resident's pain was new and should have been assessed before any movement. The facility's investigation concluded that there was no evidence of abuse, neglect, or mistreatment, but the deficiency in pain management was evident.
Plan Of Correction
Plan of Correction: Approved January 21, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #1 was identified as being directly affected by the alleged gap in practice. The facility did not ensure that pain management is provided to resident who require such services consistent with professional standards of practice and the comprehensive person-centered care plan. - An investigation was conducted and concluded that there was no evidence to support that abuse, neglect or mistreatment may have occurred. - Resident #1 was transferred to the hospital on [DATE] and readmitted to Kings Harbor on 2/15/24. - Upon resident #1 readmission from the hospital: - A Pain Assessment was completed - Resident #1 was evaluated by PMD and Tylenol 325mg q 6 hours for 14 days was ordered for pain management. - Care Plan #131A Pain Management was updated. - Resident #1 was monitored for pain and the effectiveness of pain management. - LPN #1 was educated on medication administration and documentation. - RN #1 was educated on pain assessment, pain management and updating Care Plan when change in resident condition is noted. - CNAs, LPNs and RNs of the Manor service were educated on reporting new onset of pain and deferring transfer/movement of resident prior to assessment by RN. 2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The facility respectfully states that all residents have the potential to be affected by the alleged gap in practice. All residents with new onset of pain in the last 30 days will be reviewed by the RNM/RNS to ensure that a pain assessment is conducted, PMD was notified, appropriate pain management was implemented, and pain care plan was updated. In the event that non-compliance was identified, it will be immediately corrected to comply with F697. Responsible Party: RNM/RNS 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not occur? An Ad Hoc QA/PI Meeting with the Administrator, DON, Medical Director, Director of QA/PI, and Staff Development was held to discuss the systemic changes that will be made to ensure that the deficient practice does not occur. 1. The Policy and Procedure for Pain Assessment, Education and Management was reviewed to assure compliance with F697 by the Administrator in conjunction with the Director of Nursing, Director of QA/PI and Medical Director and revised accordingly. The change in policy includes: - Pain assessment and Pain Management care plan update shall be performed: a. On admission/re-admission b. Quarterly and Annually for CCP Meeting c. Upon significant change in residents’ condition d. Upon any incident or accident as part of the assessment of the resident e. For any new complaint of pain identified by resident or staff f. Prior to initiation of a pain medication regime or change in pain medication regime g. Upon a change in the resident’s pain medication h. At any other time based on nursing or physician assessment Responsible Party: Administrator, DON, Medical Director, Director of QA/PI 2. Inservice education will be provided by the Inservice Coordinator/designee to all RNs and LPNs on pain assessment, management and care plan update. Highlights of the lesson plan include: - It is the policy of Kings Harbor to assess and manage resident’s pain upon admission/readmission and continually throughout their stay to assure the highest level of pain control and resident comfort. - When and how to perform pain assessment - Communicating with the medical provider when pain is identified - Documentation of pain assessment and management - Updating pain care plan as indicated in the Pain policy Responsible Party: Inservice Coordinator/Designee 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? 1. An audit tool will be developed to monitor the facility’s compliance with ensuring that all residents with new onset of pain are assessed and managed and that all appropriate documentations are completed. Responsible Party: QA/PI 2. All residents with new onset of pain will be reviewed to ensure that they are assessed, and appropriate management is implemented weekly x 4 weeks and then monthly for 3 months, using the new audit tool to ensure compliance. Any identified issues will be immediately addressed and shared at the Morning Meeting. Responsible Party: Nursing Team Leaders/ADON 3. The results of the pain audits will be analyzed for trends and patterns. Responsible Party: QA/PI Coordinator 4. Results of the pain audit will be presented and discussed at the facility monthly by QA/PI. Responsible Party: QA/PI Coordinator 5. Date for correction and the title of the person responsible for correction of deficiency. Deficiency will be corrected by (MONTH) 21, 2025, 60 days from the survey exit date. Person responsible for correction is the Administrator.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with idiopathic aseptic necrosis of the right femur and ongoing hip pain had a PRN oxycodone order every 4 hours, but the medication was delayed after the resident and CNAs reported the need for pain relief. The LPN stated the dose was not yet due and later said the resident was asleep, while the DNS said the delay occurred after an early morning fire drill and resulted in the resident going 7 hours without PRN pain medication when it could have been given every 4 hours.
Pain medication was not available for two residents, one resident’s morphine order was not received by the pharmacy and the first dose was delayed for more than a day after admission, and another resident missed several days of Lidocaine patch therapy because the facility ran out of stock. The second resident also had a physician order without a dose listed and a pain CAA that was not carried into the care plan. The resident reported increased back pain and poor sleep without the patch, while family and staff confirmed ongoing pain and missed doses.
The facility failed to manage pain according to physician orders for several residents. One resident received acetaminophen for pain rated above the ordered mild-pain range and without documented nonpharmacological interventions, two residents received hydrocodone-acetaminophen when their pain scores did not match the ordered parameters, and another resident lacked an order covering moderate pain levels. Staff interviews and MAR review confirmed the medications were not always administered as ordered.
A resident with moderate cognitive impairment, dysphasia, chronic pain, and almost constant pain did not receive scheduled pain meds on time. The resident was in severe pain during the morning, declined PT because pain meds had not yet been given, and later yelled for help while the RN struggled to administer oral meds and applied lidocaine patches even later. The RN said he was delayed by wound care for two other residents, and the PT and RN noted timely pain control may have improved participation in therapy and reduced pain during care.
A resident with cancer, a lower back condition, a right leg fracture, and palliative care needs reported severe leg pain, but scheduled methadone and morphine were not given until about 4 hours after the ordered 8:00 a.m. time. An LN said the delay happened because another LN called off and the workload increased. The DON stated meds should be given within 1 hour of the scheduled time.
A facility failed to consistently follow PRN pain medication orders for three residents with significant pain-related diagnoses, including fractures, cancer, and osteoarthritis. MAR review showed pain meds were given at pain levels that did not match the ordered severity ranges, including opioids administered when pain was documented as 0 or mild and, in one case, not given when severe pain was documented. An LPN confirmed the orders were not consistently followed and that there was no documentation explaining why.
Delayed PRN Pain Medication Administration
Penalty
Summary
The facility failed to ensure appropriate pain management for Resident 23, who was admitted with diagnoses including idiopathic aseptic necrosis of the right femur, a condition associated with pain, stiffness, and limited mobility. A physician order dated 6/19/26 directed PRN oxycodone every four hours for this condition. On 6/24/26, the resident requested pain medication after having last received oxycodone at 10:38 PM on 6/23/26, making the medication available again at 2:38 AM. According to the incident report, CNAs notified Staff 14 that the resident needed pain medication, but Staff 14 stated the medication was not yet due. The resident later went to the medication cart and again requested pain medication, and the medication was not given until about 4:45 AM, with the incident report noting it was administered at 5:02 AM. Camera review showed a CNA left the resident’s room at about 2:30 AM and went to Staff 14, and the resident was seen at the nurses’ station at about 4:30 AM speaking with Staff 14 before returning to the room. Resident 23 stated the pain medication should have been given around 2:30 AM and that the right hip hurt at all times, with pain rated 7 or 8 out of 10. Staff 14 stated the resident requested the medication too soon and that the resident was asleep when she went into the room around 4:00 AM. Staff 2, the DNS, stated the late PRN medication concern was investigated and determined that Staff 14 waited until after an early morning fire drill to provide the medication, resulting in the resident not receiving the PRN pain medication for seven hours when it could have been given every four hours. Staff 8 stated she notified the nurse two to three times about the resident’s need for pain medication.
Pain Medication Not Available and Pain Care Not Addressed
Penalty
Summary
The facility failed to ensure pain medication was available for administration for two residents, failed to clarify a physician order for a pain medication dose for one resident, and failed to initiate a care plan for pain that had been triggered on the CAA for one resident. These failures affected two of the three residents reviewed for pain and included one resident receiving hospice comfort-focused care and another resident with chronic back pain and moderate cognitive impairment. One resident was admitted to the facility by ambulance and had a hospice diagnosis of end stage heart failure. The resident had a physician order for Morphine Sulfate concentrate, 10 mg sublingually every hour as needed for pain and/or air hunger, but the July MAR documented no morphine administration on the day of admission. The MAR also included pain monitoring every shift, but no pain monitoring was documented that day. The first documented morphine dose was given about 26 hours after admission. A nursing note documented that the resident’s family requested as-needed pain medication and staff were unable to locate it, and follow-up with hospice and the pharmacy showed the prescriptions had not been received and were pending clarification regarding which pharmacy was to receive the orders. Pharmacy staff later stated the order received did not include morphine. A CNA also observed the resident appearing uncomfortable during repositioning, with grunting on movement. The second resident had diagnoses including lumbar intervertebral disc degeneration with discogenic back pain, functional quadriplegia, muscle wasting and atrophy, and abnormal posture. The resident’s MDS documented moderate cognitive impairment and occasional moderate-severe pain, and the CAA identified pain as a problem to be carried over to the care plan. However, the current care plan did not include a pain category or interventions to direct staff on pain relief. The physician order for Lidocaine External Patch listed application to the affected area once daily for mild pain, but no dose was identified. The MAR and nursing notes showed the Lidocaine patch was not administered for several consecutive days because the facility was out of stock, with one date signed as given in error. During interview, the resident stated the patch had not been applied for several days, that the resident had never refused it, and that without the patch the back pain increased to 7 to 8 out of 10 and interfered with sleep. The resident reported that Tylenol lowered the pain somewhat, but the patch maintained pain at about 2 out of 10. The resident’s family member stated the resident had pain all the time and that the Lidocaine patches helped take the edge off.
Pain medications given outside ordered parameters and missing pain-level coverage
Penalty
Summary
The facility failed to provide necessary pain management care and services for four residents. The report identified that pain medications were administered outside of ordered pain parameters, nonpharmacological interventions were not provided before medication administration, and one resident did not have an order covering all pain levels. The facility’s pain management policy stated that residents receiving pain interventions would be monitored for effectiveness and side effects, and that nonpharmacological interventions, effectiveness of PRN medications, and physician notification would be documented. For one resident, acetaminophen 325 mg was given after the resident reported generalized pain at a level of 6 on a 0 to 10 scale, even though the order was for mild pain only, defined as 1 to 4. The nurse did not offer or provide any nonpharmacological interventions before giving the medication, and the medication was administered outside the ordered parameters without notifying the physician. The resident’s record showed capacity to make his own medical decisions. For another resident, hydrocodone-acetaminophen 5-325 mg was administered multiple times when the documented pain level was outside the ordered range. The resident had an earlier order for moderate pain at 5 to 7, later changed to severe pain at 8 to 10, yet the MAR showed doses given for pain levels of 8 when the moderate-pain order was active and for pain levels of 7 after the severe-pain order was in place. Staff interviews confirmed the medication was to be given only within the physician’s ordered pain parameters. A third resident received hydrocodone-acetaminophen 10-325 mg for a pain level of 4 even though the order was for pain levels of 5 to 10. Another resident had orders for acetaminophen for mild pain and hydrocodone-acetaminophen for severe pain, but the record did not show any physician order for pain levels of 5 to 7. The resident’s MAR showed repeated use of hydrocodone-acetaminophen for severe pain, and no PRN acetaminophen was documented as given. The DON acknowledged that there should have been an order covering pain levels of 5 to 7.
Delayed Pain Medication Administration
Penalty
Summary
The facility failed to ensure pain medication was administered timely for a resident with moderate cognitive impairment, bilateral lower extremity impairment, muscle weakness, a history of TIA and cerebral infarction, dysphasia, chronic pain, and almost constant pain. The resident’s MDS indicated she received scheduled and PRN pain medication, and her care plan directed staff to administer analgesics as ordered and give pain medications per schedule to maintain therapeutic levels. Her pain interview also identified a condition that usually caused pain and that pain was typically worse in the morning. On the morning of the observation, the resident had not yet received her scheduled pain medications, including acetaminophen ER, gabapentin, hydromorphone, and lidocaine patches. During PT arrival, she declined therapy and stated she was in too much pain and had not received pain medication yet. When the RN later came to assess and medicate her, the resident was in significant pain, yelling for help and reporting pain in her stomach, arms, and legs. The RN had difficulty administering the oral medications because of swallowing difficulty and left to get applesauce, delaying completion of the scheduled pain medications until later in the morning. During repositioning and incontinent care, the resident verbalized increased pain with each turn, and the lidocaine patches were applied even later. The RN stated he was tied up with wound care on two other residents and confirmed the pain medications were given very late; the PT and RN both stated timely pain medication may have allowed the resident to participate in therapy and experience less pain during morning care. The DON stated the expectation was that residents receive pain medications on time, within one hour before or after the scheduled time.
Delayed Administration of Scheduled Pain Medications
Penalty
Summary
Safe, appropriate pain management was not provided for one sampled resident when scheduled pain medications were not administered as ordered. Resident 13 had diagnoses including secondary malignant neoplasm of the brain, spondylosis of the lumbosacral region, a right tibia and fibula fracture, and was receiving palliative care services. The resident’s MDS showed a BIMS score of 10/15, indicating moderate cognitive impairment. During a concurrent observation and interview, the resident was awake and reported leg pain rated 15/10, and the resident told CNA 1 that she was experiencing pain. The resident’s OSR and medication administration history showed methadone 10 mg/mL, 0.5 mL by mouth every eight hours for pain management, scheduled for 8:00 a.m., and morphine sulfate oral solution 20 mg/mL, 1 mL by mouth every eight hours for pain or shortness of breath, also scheduled for 8:00 a.m. Both medications were not administered until about 12:21 p.m. and 12:22 p.m. LN 1 stated the medications were given around noon and acknowledged they were scheduled for 8:00 a.m., explaining the delay was due to another LN calling off and an increased workload. LN 1’s note stated the resident received routine pain medications late and did not appear to be in pain at that time. The DON stated the expectation was for nurses to address and manage residents’ pain and that medications should be administered within one hour before or after the scheduled time.
Inconsistent PRN pain medication administration
Penalty
Summary
The facility failed to ensure safe, appropriate pain management for three residents whose PRN pain medication orders were not consistently followed. Resident 1 was admitted with diagnoses including vertebral fracture, lung cancer, and diabetes, had moderately impaired cognition, and was assessed as receiving PRN pain medications. Her care plan addressed chronic pain related to a general body recent injury, and her physician ordered acetaminophen 500 mg every 4 hours as needed for pain rated 1-4, hydrocodone-acetaminophen 1 tablet every 4 hours as needed for moderate pain rated 4-7, and hydrocodone-acetaminophen 2 tablets every 4 hours as needed for severe pain rated 8-10. Resident 1’s MAR showed acetaminophen was given when pain was documented at 8, 5, 7, and 5, and hydrocodone-acetaminophen 1 tablet was given when pain was documented at 3. The MAR also showed hydrocodone-acetaminophen 2 tablets was not given when pain was documented at 8. During interview and record review, LN 2 confirmed the pain medication orders were not consistently followed and that there was no documentation explaining why the orders were not followed. Resident 3 was admitted with diagnoses including right hip fracture, bone cancer of the lower right leg, cancer of connective and soft tissue, and right leg pain, and had moderately impaired cognition. Her care plan addressed acute pain due to cancer diagnosis, and her physician ordered hydromorphone 4 mg 1 tablet every 4 hours as needed for moderate pain rated 4-7 and 2 tablets every 4 hours as needed for severe pain rated 7-10. The MAR showed 1 tablet was given when pain was documented at 9, 9, 9, and 8, and 2 tablets were given when pain was documented at 0, 3, 3, 6, 6, 6, 6, 2, 2, 6, and 6. LN 2 confirmed the orders were not consistently followed and that there was no documentation explaining why. Resident 4 was admitted with diagnoses including osteoarthritis, difficulty walking, and depressive episodes, had intact cognition, and was receiving scheduled pain medications, PRN pain medications, and non-medication interventions for pain. Her care plan addressed pain or discomfort related to bilateral osteoarthritis, left hand discomfort/tingling, and right foot pain. Her physician ordered oxycodone 5 mg 1 tablet every 4 hours as needed for moderate pain and 2 tablets every 4 hours as needed for severe pain. The MAR showed 1 tablet was given when pain was documented at 0, and 2 tablets were given numerous times when pain was documented at 0, 1, 2, 3, 4, 5, and 6. LN 2 confirmed the pain medication orders were not consistently followed, and there was no documentation explaining why the orders were not followed. The DON stated nurses should administer PRN pain medications based on assessed pain severity and that the assessed 0 pain levels were probably follow-up assessments after pain medication.
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