Failure to Assess and Manage Pain After Fall in Cognitively Impaired Resident
Summary
A cognitively impaired resident with severe dementia and communication deficits experienced a fall during a transfer, in which he struck his left side on a wheelchair. The certified nursing assistant (CNA) involved in the incident did not report the fall to nursing staff or supervisors, and the resident was moved without a licensed nurse first assessing his condition, contrary to facility policy. Following the fall, the resident exhibited new onset pain and required increased assistance with transfers, but these changes were not appropriately assessed or reported to the physician for further intervention. Multiple staff members, including CNAs and LPNs, observed or were informed of the resident's complaints of pain and changes in mobility throughout the day following the fall. Despite these observations and reports, a thorough pain assessment was not conducted, and the resident did not receive any pain medication until the following morning. The resident's pain was only formally assessed after further complaints and visible signs of pain, at which point an x-ray was ordered, revealing a displaced comminuted intertrochanteric femur fracture. The resident, who had a history of muscle wasting, osteoporosis, dementia, Alzheimer's disease, and aphasia, was unable to effectively communicate the extent of his pain due to his cognitive impairment. Staff interviews confirmed that the resident did not normally complain of pain and that his new complaints were not adequately investigated. The failure to assess, report, and treat the resident's pain in a timely manner resulted in a delay in diagnosis and appropriate pain management for a significant injury.
Removal Plan
- All residents who were identified as cognitively impaired were assessed to see if they showed any signs or symptoms of pain. A thorough review of each of the cognitively impaired residents fall risk assessment was completed by the Clinical Care Coordinators.
- All staff were trained by the Administrator, DON, or designee to report any observed or verbalized pain or any change of condition immediately to a nurse or an administrative team member. The nurse or an administrative nurse will follow the standing or PRN orders and will follow up with their MD.
- All nurses were in-serviced to ensure a proper pain assessment was completed when a resident reports or shows any signs of pain to a staff member.
- Monitoring was implemented to assess resident pain with interviews of a random sample of nurses including a specific section asking residents about pain during transfers.
- Daily huddles with administrative staff in random facility sections asking nurses and CNAs about any observations of pain or incidents that occurred during their shift. These huddles will be conducted daily for 2 weeks, then monthly thereafter for 3 months.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with chronic pain syndrome and frequent severe pain missed multiple doses of an ordered lidocaine cream because the medication repeatedly ran out. Nursing and central supply staff confirmed the OTC cream was not consistently available after a vendor change, and the resident stated the left shoulder pain was not managed without it.
Failure to Assess and Manage Ongoing Pain After a Fall: A resident with severe cognitive impairment and multiple chronic conditions was found on the floor and later had repeated therapy notes documenting persistent RLE pain, limited mobility, and inability to bear weight. The record did not show follow-up pain assessments or pain medication administration despite reports of hip, thigh, and leg pain, and the resident was later hospitalized with a displaced femoral neck fracture and right hip tenderness.
Incomplete PRN Narcotic Pain Documentation: The facility failed to document pain assessments and reevaluations for PRN narcotic pain meds for four residents. MARs and controlled substance records showed multiple Hydrocodone-Acetaminophen and Tramadol doses removed or administered without the required documentation, despite care plans addressing pain and opioid use. Staff interviews confirmed awareness that PRN meds must be documented on the MAR and that missing documentation could allow a narcotic to be given too soon.
A resident with chronic back pain, disc degeneration, and spinal stenosis waited an extended period for an MRI required before a pain specialist appointment. The record showed the clinic requested the MRI and PT before the initial visit, but the facility did not timely complete the scheduling process, with the DON relying on a desk calendar entry that was not entered into the EHR and the hospital stating the MRI was only scheduled after the facility called in.
Failure to Escalate Unrelieved Pain When Physician Did Not Respond: A resident with cancer-related pain and severe pain scores was ordered gabapentin and later acetaminophen, but refused Tylenol because it did not relieve the pain. Staff documented contacting the NP and attending MD for stronger pain medication, yet the physician did not respond and the DON stated there was no attempt to contact the Medical Director. The resident later developed intractable left flank pain and was transferred via 911 for further care.
Inadequate pain management and documentation for a resident after hospital return. A resident came back from the hospital after a heel debridement with an order for Percocet PRN, but staff delayed clarifying the order, offered Tylenol while the resident reported being told to avoid it with Percocet, and did not document the pain assessment or nonpharmacological interventions. The resident reported severe pain, said staff argued about the medication, and later received a one-time higher Percocet dose after the physician documented ongoing pain.
Missed ordered pain cream doses due to unavailable stock
Penalty
Summary
The facility failed to ensure a resident’s ordered pain medication was available for administration, resulting in 17 missed dose opportunities out of 186 for one sampled resident. The resident was admitted in 11/2021 with diagnoses including chronic pain syndrome, was cognitively intact, and had an annual MDS indicating frequent pain in the previous five days with a reported pain level of 9 out of 10. The physician ordered Aspercreme Lidocaine Cream 4% to be applied to the resident’s neck and left shoulder twice daily for pain, but review of the 3/2026, 4/2026, 5/2026, and 6/2026 TARs showed multiple missed AM and PM doses because the medication was not available. During interview, the resident stated the facility had run out of the lidocaine cream multiple times, including most recently the week before the interview, and stated the left shoulder pain was not managed without it. Staff stated creams were administered by nursing staff, that low supply should be monitored and refills requested, and that central supply was responsible for obtaining the OTC cream when stock was low. Staff confirmed the resident missed multiple doses because the Aspercreme ran out, and central supply stated the product had run out multiple times after a vendor change because the new vendor did not carry it, so it was being purchased through Amazon.com and local stores that did not consistently have it in stock.
Failure to Assess and Manage Ongoing Pain After a Fall
Penalty
Summary
The facility failed to follow its pain management policy by not adequately assessing, monitoring, or managing pain for one resident who had a fall and later developed ongoing right lower extremity pain. The resident was admitted with multiple diagnoses including weakness, anxiety disorder, insomnia, severe protein calorie malnutrition, major depressive disorder, constipation, alcohol abuse, gastroesophageal reflux disease, cognitive communication deficit, metabolic encephalopathy, difficulty walking, and a history of breast cancer. The resident’s BIMS score on the MDS was 4/15, indicating severe impairment. After an incident in which the resident was found on the floor on her right side next to her bed, the incident report documented lacerations and redness to both knees, a laceration to the right ankle, redness to the right hip, and that the resident reported no pain at that time. However, therapy documentation later repeatedly recorded pain in the right hip, thigh, and right lower extremity, including pain ratings ranging from 3/10 to 8/10, pain with movement, and limitations in ADLs, mobility, standing, bending, and weight-bearing. Therapy notes also documented that the resident was unable to ambulate at times due to severe pain and had decreased range of motion related to contracture. The resident’s medical record did not document pain assessments after pain was recorded in therapy notes, and the MAR did not document any pain medication administration from 11/24/25 through 12/12/25. Staff interviews indicated that therapy staff reported pain to nursing when it occurred, and the DON stated pain should be reported to the provider and followed up if medication was ineffective, but no pain assessments or investigation of the resident’s complaints were presented during the survey. The resident was later sent to the hospital when family requested transfer, and the hospital record documented right hip pain, tenderness to palpation and with range of motion, and a right femoral neck fracture on x-ray, with the hospital noting the fracture may have been due to a fall two weeks prior to presentation.
Incomplete PRN Narcotic Pain Documentation
Penalty
Summary
The facility failed to ensure pain assessments were completed before and after the administration of PRN narcotic pain medications for four sampled residents: R4, R8, R16, and R18. Facility policies for Pain Management and PRN Medication required use of a pain assessment tool appropriate to the resident’s cognitive status, documentation of the reason for PRN use, the time of administration, and evaluation of effectiveness. The policies also stated that pain management would be reassessed at established intervals for effectiveness and adverse consequences. R18 was admitted with diagnoses including cerebral infarction, neuralgia, and unspecified pain, and her care plan included pain-related interventions and opioid-related goals. Her MAR showed documented administrations of Hydrocodone-Acetaminophen with pain assessments before and after administration, but the Medication Monitoring/Control Record showed additional tablets removed that were not documented on the MAR. For March 2026, 17 tablets were removed and 13 PRN doses were missing from the MAR, including pain assessment and reevaluation. For April 2026, 10 tablets were removed and 8 PRN doses were missing from the MAR, also without the required pain assessment and reevaluation. R4 was admitted with diagnoses including diastolic heart failure, wedge compression fracture of T11-T12 vertebra, and unspecified pain. Her care plan identified pain related to age, decreased mobility, restless leg syndrome, muscle spasms, and opioid use. Her MAR showed one documented Tramadol administration in March 2026, one in April 2026, and none in May 2026, while the Medication Monitoring/Control Record showed 9 tablets removed in March, 6 in April, and 7 in May. In each month, multiple PRN doses were missing from the MAR, including pain assessments and reevaluations before and after administration. R16 was admitted with cerebrovascular disease, Alzheimer’s disease with late onset, and idiopathic neuropathy. Her care plan addressed pain related to hip fracture history, decreased range of motion, arthritis, weakness, CVA, and muscle weakness. Her MAR showed no documented Hydrocodone-Acetaminophen administrations in April 2026 and one documented administration in May 2026, while the Medication Monitoring/Control Record showed 5 tablets removed in April and 9 in May. In both months, PRN doses were missing from the MAR, including pain assessment and reevaluation. R8 was admitted with Type 2 diabetes mellitus with hyperglycemia, unspecified myalgia, and acquired absence of the left foot and right great toe. Her care plan addressed acute pain related to toe amputation and opioid use. Her MAR showed no documented Hydrocodone-Acetaminophen administrations in March 2026, four documented administrations in April 2026, and none in May 2026, while the Medication Monitoring/Control Record showed 5 tablets removed in March, 16 in April, and 7 in May. In each month, PRN doses were missing from the MAR, including pain assessments and reevaluations before and after administration.
Delayed MRI Scheduling for Pain Specialist Referral
Penalty
Summary
The facility failed to timely schedule an imaging appointment needed before a pain specialist visit for a resident with chronic back pain. The resident had diagnoses including intervertebral disc degeneration with lumbar discogenic back pain and lower extremity pain, and spinal stenosis. The quarterly MDS indicated the resident was cognitively intact, used a wheelchair, needed substantial to maximal assistance with transfers, and received scheduled pain medication. During interview, the resident stated their back had been hurting really bad and that they had been waiting a long time for the back scan required before seeing the pain specialist. The record showed a physician order to refer the resident to an interventional pain and spine clinic for chronic back pain, followed by a note that a message was left for the pain clinic. Later documentation stated the pain clinic requested an MRI and 6 weeks of PT before the initial appointment. The clinical team attempted to schedule the MRI and was awaiting hospital scheduling, while an LPN later stated the hospital said a referral order was needed before the MRI could be scheduled and that the nurse practitioner was notified. The DON stated the facility had sent the order to central scheduling and was waiting for a date and time, and also stated an appointment date was written on a desk calendar but was not entered into the EHR. Central scheduling stated the MRI was ultimately scheduled after the facility called in.
Failure to Escalate Unrelieved Pain When Physician Did Not Respond
Penalty
Summary
The facility failed to effectively manage one resident’s pain in accordance with its Pain Assessment and Management policy. The resident was admitted with diagnoses including type II DM, malignant neoplasm of the female genital organs, and hemorrhage of the anus and rectum. The resident’s hospital history and physical indicated Dilaudid 0.5 mg IVP every four hours as needed, and the facility’s pain assessment documented severe pain rated 7-8/10 in the lower abdomen related to vulvar cancer, with an acceptable pain level of 0/10. The pain management plan stated that the physician should be notified if the current regimen was ineffective. The resident was ordered gabapentin 300 mg every 12 hours and later acetaminophen 650 mg every six hours for pain and fever. On 5/14/2026, the resident refused acetaminophen, stating it did not help and would not work. Progress notes documented that staff sent a text to the NP requesting stronger pain medication and later noted that the RN supervisor was aware and in contact with the doctor, with staff awaiting an MD order. Another note documented that the resident complained of pain but refused Tylenol, that the MD was notified, and that staff were waiting for a new pain order. By 5/15/2026, the resident was documented with intractable left flank pain and was transferred via 911 to another hospital due to the pain. During interviews, LVN 1 stated the resident reported severe pain and refused acetaminophen because it did not provide relief, and that LVN 1 contacted the NP and reported the issue to the oncoming nurse for follow-up. LVN 2 stated staff were still awaiting the physician’s response and had not received a response since the prior day. The DON stated staff must contact the Medical Director if the attending physician did not respond, but there was no attempted contact to the Medical Director on 5/14/2026 or 5/15/2026, despite messages to the attending physician requesting stronger pain medication and documentation of ongoing severe pain.
Inadequate Pain Management and Documentation for a Resident After Hospital Return
Penalty
Summary
Facility staff failed to provide appropriate pain management for a resident who had recently returned from the hospital after a heel wound debridement procedure. The hospital discharge summary documented Percocet 5-325 mg, 1 tablet every 4 hours as needed, and the resident was re-admitted to the facility on 1/7/26 at 8:30 PM. According to the record, the resident began complaining of pain at about 10:00 PM, and the assigned LPN realized the admission orders had not yet been signed off by the physician. The LPN documented that she offered Tylenol while waiting for the Percocet order to be signed, but the resident refused all pain medications offered. She did not document when the resident first requested pain medication, an assessment of the pain, or any nonpharmacological interventions offered. She also did not document that the resident stated he/she had been told to avoid additional Tylenol while taking Percocet, or that she educated the resident about that issue. The telehealth provider later documented that the resident reported pain at 10/10 and appeared lethargic, and did not want to increase the Percocet dose at that time, though it should be considered due to uncontrolled pain. The physician later documented that the resident had been having pain since admission and entered a one-time order for Percocet 5/325 mg, 2 tablets for pain management. The LPN documented that the resident received the 2 tablets and had no further complaints of pain. During interviews, the resident stated that staff only offered Tylenol, that he/she had told the nurse about being instructed not to take Tylenol with Percocet, and that when Percocet was finally given it was 1 tablet instead of the 2 tablets received in the hospital. The LPN, RN supervisor, DON, and administrator were interviewed, and the LPN and supervisor acknowledged they had not clarified the Percocet order with the hospital, had not offered nonpharmacological interventions, and had not documented the timing and details of the pain management events.
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