Failure to Manage Resident's Pain After Fall
Summary
The facility failed to effectively manage the pain of a resident following an unwitnessed fall, which resulted in a left subcapital femoral neck fracture. The incident occurred when the resident fell in her room and reported left leg and knee pain to two LPNs. Despite receiving one dose of PRN Tylenol, there was no documentation on the medication administration record (MAR), and the resident continued to exhibit signs of pain, such as yelling out and facial grimacing. The on-call Nurse Practitioner ordered an x-ray and an ice pack for pain, but no additional pain medications or interventions were provided until the resident was sent to the hospital approximately 19 hours later. The resident, who had a history of major depressive disorder, generalized anxiety disorder, and atrial fibrillation, was at risk for falls and had a recent pain assessment indicating no pain in the last five days. After the fall, the resident expressed pain at a level of six out of ten and showed nonverbal signs of pain. The fall investigation revealed that the resident attempted to transfer and ambulate herself, leading to the fall due to weakness and poor safety awareness. Despite these findings, there was no documentation of pain levels on the MAR, and the resident's pain was not adequately addressed. Interviews with staff and review of facility policies highlighted the lack of appropriate pain management. The Director of Nursing confirmed that the resident showed multiple signs of pain after the fall, but there was no documentation of pain medications being administered before the resident was sent to the hospital. The facility's pain management policy emphasized the need for timely assessment and intervention for acute pain, which was not followed in this case, leading to the resident's prolonged discomfort and eventual need for surgical intervention.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with dementia, Wernicke's encephalopathy, and psychotic disorder was care planned as being at risk for pain and had scheduled Tylenol ordered for left hip pain, with an MDS indicating occasional pain that interfered with sleep. Despite a facility policy requiring every-shift pain monitoring documented on the MAR flow sheet and the DON’s expectation that all residents have a set day for pain assessments, the resident’s MARs for multiple months contained no order for routine pain monitoring and no documented pain assessments after a specific date. The resident reported fluctuating but manageable pain controlled by scheduled medication, but staff failed to consistently assess and record pain levels as required by the care plan and facility policy.
A resident with acute kidney failure, kidney stones, UTI, moderate cognitive impairment, and severe left hip osteoarthritis experienced inadequate pain management when PRN acetaminophen and later PRN oxycodone were not used or escalated in a timely and consistently effective manner. On one occasion, the resident was documented as yelling with pain rated 9/10, initially receiving only Tylenol because narcotics were noted as not due, and although oxycodone was later increased and administered, the resident was again observed yelling in pain that same afternoon. A family member reported the resident screaming in pain on another day, being told that Tylenol would not be available for some time, and that the nurse would not call the NP or physician, instead waiting for the NP’s next visit and only leaving a log-book message. These events occurred despite facility policies requiring prompt physician notification for changes in condition and pain management consistent with professional standards.
A resident with a history of severe intractable migraines and hypertension was admitted with orders for multiple pain and blood pressure medications, including newly ordered Topamax for migraine prophylaxis and PRN Imitrex for acute migraines. Facility records showed incomplete vital sign and pain assessments, and the MAR/TAR documented that the ordered Topamax and Imitrex were never administered, while pain scores were marked as not applicable despite documented severe headaches, vomiting, and prior high pain ratings. On one shift, an LPN, covering both Assisted Living and the skilled unit, acknowledged not giving the ordered migraine medications or PRN Tylenol, administering only scheduled Gabapentin and being unaware of the Imitrex order. The resident’s daughter found the resident covered in vomit, requested transfer, and the resident was sent to the hospital without a completed transfer form, where she was admitted for intractable headaches/migraines and hypertensive emergency. The resident, her daughter, and the DON later confirmed that ordered migraine medications were not given and blood pressure monitoring was not performed in accordance with the facility’s pain management policy.
A cognitively intact resident with osteoarthritis and other comorbidities had a physician’s order for PRN Voltaren gel to the right shoulder for pain, but the MAR showed no administrations over multiple days. The resident reported requesting the PRN medication on several occasions and being told by nurses that it was not available. An LPN confirmed the resident had an active order, had requested the medication, and that the Voltaren gel was out of stock, resulting in the resident not receiving the ordered pain management.
A resident with chronic back and joint pain, receiving multiple scheduled and PRN pain medications including oxycodone ER, Lyrica, lidocaine patches, and muscle relaxants, did not consistently receive these medications at the ordered times. Audit reports and MARs showed numerous late or missed doses, medications documented as not available, and administration outside the facility’s defined time windows for "upon rising," dinner, and bedtime, without documented reasons in nursing notes. The resident reported that pain medications were not always given on time, experienced pain scores up to 10/10, and stated that pain at moderate levels was not tolerable without intervention. The DON confirmed the late administration times and acknowledged being previously unaware of the pattern of late pain medication administration.
A resident with multiple fractures and a care plan goal for adequate pain control had PRN orders for acetaminophen for mild to moderate pain and Roxicodone for severe pain defined as 8–10 on a 1–10 scale. Nursing staff repeatedly administered PRN Roxicodone when the resident’s documented pain scores were below the ordered threshold, including doses given for pain levels of 7 and once for a pain level of 0, instead of using the ordered acetaminophen for lower pain levels. An LPN and an RN confirmed that the narcotic was given outside the prescribed parameters, contrary to the facility’s medication administration policy requiring medications to be given as ordered.
Failure to Routinely Monitor and Document Resident Pain Levels
Penalty
Summary
The deficiency involves the facility’s failure to ensure routine monitoring and documentation of pain levels for a resident who required pain management. The resident was admitted with diagnoses including Wernicke's encephalopathy, psychotic disorder with hallucinations, and dementia, and had a care plan dated 05/15/25 identifying the resident as at risk for pain/discomfort. Care plan interventions included administering medications as ordered, monitoring for effectiveness, and assessing and documenting the resident’s pain location, duration, frequency, intensity, and negative findings. A physician’s order dated 07/23/25 directed Tylenol 325 mg, two tablets every six hours for left hip pain, and an MDS assessment dated 12/22/25 documented that the resident was cognitively intact and experienced occasional pain that made it hard to sleep on several days during the review period. Review of the MARs for February and March 2025 showed no order for routine pain monitoring and no documentation of any pain assessment after 02/25/26. The DON confirmed that all residents should have a set day for pain assessments, that this resident’s record lacked a physician’s order for routine pain monitoring, and that the MARs contained no documented pain assessments since 02/25/26. The resident reported that pain levels fluctuated but were manageable and that scheduled pain medication was typically effective. Facility policy titled “Pain Management and Assessments” stated that all residents would be monitored for pain every shift by nursing staff, with this information tracked on the pain section of the MAR flow sheet, which was not done in this case.
Plan Of Correction
F 0697 DON assessed Resident #20 on 03/26/2026. There were no negative effects related to the resident's lack of Pain Assessment completion that was identified during the Annual Survey. LNHA notified Primary care provider of lack of Pain Assessment completion on 03/26/2026. Primary care provider has no new orders currently. On or before 04/30/2026, DON/Designee will meet with interdisciplinary team (IDT) to review facility policy & procedure regarding monitoring pain. At this time, the IDT will ensure that the facility's policy & procedure requires all like residents' pain be monitored by licensed nursing staff every shift. On or before 04/30/2026, licensed nursing staff will be educated on: §483.25(k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Also, on or before 4/30/2026, licensed nursing staff will be educated on the requirement that pain observation & documentation must occur every shift for all like residents. DON/Designee will perform Pain Assessment audits of x5 medical records x4 weeks; then as determined by QAA to ensure proper documentation is complete. The audit will list identifier (facility identifier), current pain observation reflected in physician's order; pain observation completion; and follow-up interventions completed for any reports of pain
Failure to Provide Timely and Effective Pain Management for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate pain management for a resident with multiple medical issues, including acute kidney failure, kidney stones, urinary tract infection, and primary osteoarthritis of the left hip. The resident had moderate cognitive impairment and reported pain in multiple areas, including his hip, arms, legs, and teeth. Physician orders initially included PRN acetaminophen 325 mg every four hours for pain, which was later discontinued, and then PRN oxycodone 2.5 mg every eight hours for pain. Documentation showed that on one date the resident received acetaminophen for a pain level of six, which was not effective, followed by another dose that was effective. An orthopedic note documented the resident’s left hip pain and the plan for further interventions, including urology and dental evaluations. On another date, the resident’s pain escalated significantly. At approximately midday, the resident was documented as yelling out with pain rated 9/10. At that time, narcotics were noted as “not due,” and Tylenol was administered while the NP was notified. Shortly thereafter, the NP ordered an increase in oxycodone to 5 mg every eight hours PRN, and a dose was administered. The MAR and controlled drug record indicated that the oxycodone dose was effective at a later assessment, with the resident resting; however, an observation later that same afternoon found the resident in bed yelling out that he was in pain. The ADON later stated she did not hear the resident if he hollered out after the oxycodone administration. Family interviews revealed additional concerns about pain management on an earlier date. A family member reported that the resident was screaming in pain and that staff told her Tylenol would not be available for another 40 minutes. The family member stated she had to locate staff to assist the resident and provide pain medication, and that the LPN on duty said the NP would not be in until the next day and would not address the resident’s pain, and that the nurse would not call the physician. The LPN later confirmed she was aware of the family’s concerns, gave Tylenol, did not recall if the resident was hollering in pain, and did not call the NP because the NP preferred to see residents in person for narcotic pain medications, instead leaving a message in the log book for the physician. These actions and inactions occurred despite facility policies requiring notification of the physician and representative upon changes in condition and administration of pain medications in accordance with professional standards of practice.
Failure to Administer Ordered Migraine Medications and Monitor Pain/Blood Pressure
Penalty
Summary
The deficiency involves the facility’s failure to implement a comprehensive, individualized, and effective pain management program for a resident with a known history of severe, intractable migraines. The resident was admitted with diagnoses including migraine without aura, intractable, with status migrainosus, anxiety, depression, cerebrovascular disease, fibromyalgia, and hypertension. Admission orders included Aspirin, Gabapentin, Losartan, Metoprolol, and PRN Acetaminophen for pain. Early documentation showed incomplete vital signs and pain assessments on 11/26, and on 11/27 the resident reported posterior neck pain rated 4/10, occurring daily, with an assessment indicating she was alert and oriented. The care plan for potential alteration in comfort related to fibromyalgia directed staff to administer medications as ordered and per resident preference/request, encourage early reporting of pain, and observe for signs and symptoms of pain. Over the next two days, the resident experienced escalating pain and migraine symptoms. On 11/27, an LPN documented administering Acetaminophen 325 mg (two tablets) for a headache unrelieved by environmental measures, with the medication noted as effective. On 11/28 at 3:16 A.M., another LPN documented the resident was vomiting and complaining of headaches causing her to vomit; Tylenol 325 mg (two tablets) was given and documented as effective. Later on 11/28, after discussion among the nurse, the resident, and the resident’s daughter with a nurse practitioner, new orders were obtained for Topamax for migraines, Imitrex PRN for acute migraines, Magnesium, and Perphenazine, along with a psychiatry consult. However, review of the MAR/TAR for November showed no evidence that Topamax or Imitrex were administered after these orders were written, and pain levels on 11/28 and 11/29 were marked as not applicable despite prior documentation of pain scores of 8 and 10 and the MDS indicating frequent severe pain affecting sleep and daily activities. On 11/29, the resident’s daughter contacted the facility reporting that her mother had not received her medications. The assigned LPN later stated she was responsible for both Assisted Living and the skilled unit that day, and that when the daughter called, she told her she was preparing to pull the resident’s medications. The LPN acknowledged she did not administer Topamax because she believed it was scheduled for the afternoon and was unaware of the new Imitrex PRN order from the previous day. She confirmed that neither Topamax nor Imitrex had been administered and that she did not give PRN Tylenol for the resident’s headache, only the scheduled Gabapentin. The daughter subsequently arrived at the facility, found the resident covered in vomit with vomit on the floor, and requested transfer to the emergency room. The LPN obtained an order to send the resident to the hospital but did not complete a transfer form. Hospital records documented admission for intractable headaches with vomiting and hypertensive emergency, with an emergency room blood pressure of 200/100 mm/Hg and severe headache rated 9/10. The resident, her daughter, and the DON later confirmed that ordered migraine medications were not administered and that blood pressure monitoring was not performed as required, in contrast to the facility’s pain management policy, which required daily pain monitoring and assessment before and after PRN pain medication administration. The resident and her daughter reported that the resident did not receive her migraine medications as ordered and that her blood pressure was not adequately monitored, leading to rehospitalization three days after admission. The daughter stated she frequently could not reach staff by phone and often could not find staff when visiting, and that her calls to the DON were not returned. The resident reported that she believed she was supposed to receive Hydralazine for migraines, as she had prior to admission and in the hospital, but did not think she was receiving all of her medications correctly at the facility. The DON confirmed that the resident did not receive her ordered medications and that staff failed to monitor her blood pressure, and the facility’s pain management policy specified recognition, evaluation, and management of pain consistent with assessment and care plan, including daily monitoring of pain levels and assessment of PRN pain medication effectiveness. These documented failures culminated in the resident’s transfer and hospitalization for intractable migraines with vomiting and hypertension.
Failure to Provide Ordered PRN Pain Medication Due to Out-of-Stock Voltaren Gel
Penalty
Summary
Facility staff failed to provide ordered and requested pain management for a cognitively intact resident with osteoarthritis, obstructive sleep apnea, and congestive heart failure. The physician had ordered Voltaren gel to be applied topically to the resident’s right shoulder every six hours as needed for pain. Review of the March 2026 MAR showed no documentation of Voltaren gel administration on 03/07/26, 03/08/26, 03/09/26, and 03/10/26. The resident reported that on each of those dates he requested his PRN Voltaren gel, but nurses told him it was not available. An interview with an LPN confirmed the resident had a physician’s order for Voltaren gel, had asked for it to be applied to his right shoulder, and that the medication was out of stock. This resulted in the resident not receiving the ordered PRN pain medication despite multiple requests. This deficiency represents noncompliance investigated under Complaint Number 1360651.
Failure to Administer Pain Medications as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer ordered pain medications in a safe and timely manner to effectively manage a resident’s pain. The resident was cognitively intact, had chronic pain conditions including left hip pain, osteoarthritis of the left knee, lumbar disc degeneration, lumbar back pain, and right foot pain, and was care planned as being at risk for back pain, fatigue, anxiety, and bone pain with an intervention to administer medications as prescribed. Physician orders included scheduled oxycodone ER twice daily (upon rising and at 7:00 P.M.), PRN oxycodone doses, a daily lidocaine 4% patch upon rising, Lyrica 75 mg three times daily, and later Baclofen and methocarbamol as muscle relaxants. The facility’s policy required medications to be administered in a safe and timely manner and in accordance with ordered time frames. Review of the medication administration audit reports and MARs for January and February showed numerous instances where the resident’s scheduled pain medications and related therapies were given late, given at times outside the defined administration windows, or not available and therefore not administered. Examples included Lyrica doses scheduled for 2:00 P.M. and 10:00 P.M. being given hours late or the following morning, lidocaine patches ordered for “upon rising” being applied in the early afternoon or evening, and oxycodone ER doses ordered for “upon rising” or 7:00 P.M. being administered late at night or the next morning. There were also documented instances where Lyrica doses at multiple times in a day were not available, and methocarbamol and oxycodone ER doses were not administered as ordered. On several dates, multiple scheduled medications (Lyrica, oxycodone ER, lidocaine patch, Baclofen) were consistently administered outside the facility’s defined time ranges for “upon rising,” “dinner,” and “bedtime.” Nursing progress notes for January and February did not document reasons for the late administration of medications, except for the not-available notations for Lyrica on specific dates. Pain ratings documented on the MAR showed the resident reporting pain levels of six out of 10 and 10 out of 10 on multiple occasions during this period. The resident reported that pain medications were not always given on time, that she had chronic back pain, and that she needed her pain to be tolerable to participate in therapy with a goal of returning home, stating that pain at a level of five or six out of 10 was not tolerable without intervention. The DON confirmed the late administration times identified in the audit reports, stated she had never seen a medication administration audit report before, was not aware that medications were being administered late, and did not know why the resident’s pain medications were administered late.
Narcotic Pain Medication Administered Outside Ordered Parameters
Penalty
Summary
The deficiency involves the facility’s failure to administer narcotic pain medication according to the physician’s ordered parameters for a resident with multiple fractures and other comorbidities. The resident was admitted with diagnoses including nondisplaced right humerus fracture, lumbar vertebral fractures, morbid obesity, fall, anxiety disorder, and alcohol use. The baseline care plan identified the resident as alert and aware, with goals for physical and occupational therapy and adequate pain control. Physician orders included PRN acetaminophen 500 mg every six hours for mild to moderate pain and PRN Roxicodone (oxycodone HCl) 5 mg every six hours for severe pain, defined as a pain level of 8–10 on a 1–10 scale. Record review showed that staff administered the PRN Roxicodone outside the ordered parameters on multiple occasions. Under the first Roxicodone order, the resident received the narcotic for pain scores of 7 on several dates and once for a documented pain level of 0, even though the order specified use only for severe pain (8–10). After the order was refilled, the resident again received Roxicodone for a pain level of 7, which was below the ordered threshold. In total, there were eight administrations under the first order and one under the second order when the resident’s pain level was below 8. Staff interviews with an LPN and an RN confirmed that the PRN narcotic was given outside the ordered parameters and that acetaminophen, ordered for mild to moderate pain, should have been used when pain levels were below 8. The facility’s medication administration policy required medications to be administered safely, timely, and as prescribed.
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