Failure to Provide Timely Pain Management and Hospital Transfer After Fracture
Summary
A deficiency occurred when a resident with a history of multiple sclerosis, lack of coordination, and dependency for transfers sustained a fracture to the left tibia after an incident involving a shower chair. The resident reported pain and an x-ray was ordered, which confirmed the fracture. However, there was a significant delay in notifying the nurse practitioner (NP) of the x-ray results, and the resident was not transferred to the hospital until five days after the injury. During this period, documentation and communication regarding the resident's pain and the abnormal x-ray findings were inconsistent and unclear among nursing staff and the DON. Pain assessments documented in the medication administration record (MAR) did not consistently reflect the resident's reported pain levels, with most shifts indicating no pain despite the resident's statements of ongoing pain after the fracture. As-needed pain medication was not administered on the day of the injury, and the resident reported that the pain medication provided was not effective in managing her pain prior to hospital transfer. The resident also experienced a second fracture to the right leg under similar circumstances, again reporting pain and delayed transfer to the hospital. Interviews with staff revealed confusion about the process for notifying the NP and following up on critical results, as well as uncertainty about the appropriate steps to take when pain or injury was identified. The facility's policies required prompt assessment and management of pain, especially in cases of fractures, but these protocols were not followed. The failure to provide timely and appropriate pain management, accurate assessment, and documentation resulted in the resident experiencing unnecessary pain and delayed medical intervention.
Removal Plan
- All residents were immediately assessed for any change in condition from their baseline including pain assessment.
- Any resident who verbalized or showed nonverbal signs of pain was addressed at that time following that resident's physician orders for pain management.
- Either DON, ADON D, ADON E, or LVN CC will round the center and observe each resident every 12 hours looking for indications of pain or change of conditions; these rounds will be documented on the resident 24-hour report.
- The ADM will monitor this process daily.
- The following in-services were immediately initiated by the Chief Nursing Officer: any nurse not present or in-serviced will not be allowed to assume their duties until in-serviced.
- The ADM and HR will ensure these team members are removed from the time clock and PCC access removed; this will be monitored until 100% complete or the team members are terminated.
- Ongoing in-service will be completed by DON, ADON D, and ADON E until all staff, weekend, and PRN are completed.
- Post-test will be completed to evaluate team members' understanding of in-services covered; the passing score will be 80% - 100%.
- Licensed nurses were in-serviced on how to assess residents for signs and symptoms of pain using a pain scale appropriate for them.
- Licensed nurses were in-serviced on how to reassess pain after medication administration for effectiveness and process for if not effective.
- Each resident will have a pain management treatment plan as part of their plan of care.
- The medical director was notified of the immediate jeopardy situation by the DON.
- The Ombudsmen was notified of this Immediate Jeopardy situation by the ADM.
- Interviews were conducted with employees to verify understanding of pain assessment, notification, documentation, and identification of pain indicators.
- Record review of facility in-service titled Following Physician Orders to Address Pain revealed all nursing staff had signed indicating education was completed by all nurses.
- Record review of facility in-service titled Assessing the effectiveness of pain medication given revealed all nursing staff had signed indicating education was completed by all nurses and CNAs.
- Record review of facility in-service titled Comprehensive Pain Management Treatment Plan revealed all nursing staff had signed indicating education was completed by all nurses and CNAs.
- The facility will ensure that all mechanical transfer train-the-trainer sessions, center random skill checks, and instances where transferring is found to be done incorrectly, will be supervised, monitored, and approved by a licensed physical therapist.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
A resident with dementia, osteoporosis, and a prior femur fracture experienced an unwitnessed fall followed by new, severe hip pain and loss of mobility. Over several days, multiple nurses and NAs observed screaming, crying, grimacing, and difficulty with transfers and ambulation, yet documentation was inconsistent, pain scores of 0 were repeatedly recorded, PRN acetaminophen was used minimally, and no thorough pain or lower extremity assessments were documented. The NP evaluated the resident for hip pain without being informed of the fall, did not assess the lower extremities, attributed the pain to nerve pain, and instructed staff to give PRN acetaminophen and educate the cognitively impaired resident to request pain medication. Aides continued to note pain with movement but sometimes did not report it, assuming nurses were aware. Days later, a supervisor documented hip discomfort and ordered mobile x‑rays, which revealed an acute displaced femoral neck fracture, after which the resident was sent to the hospital and underwent a left hip hemiarthroplasty.
A resident with a lumbar wedge compression fracture and cognitive impairment experienced significant pain, at times rated as high as eight out of ten, and was observed tearful, grimacing, and vocalizing pain during routine activities and transfers. Although PRN ibuprofen and hydrocodone-acetaminophen were ordered and administered with documented effect, the care plan also called for non-pharmacologic pain interventions such as massage, aromatherapy, warm packs, and distraction, which staff did not implement. CNAs reported the resident frequently complained of pain and confirmed they were unaware of any non-pharmacologic pain measures being used, while an administrative nurse stated staff were expected to use such interventions despite the absence of a formal pain management policy.
A resident with acute osteomyelitis of the right ankle and foot and a lumbar vertebra fracture had a care plan calling for non-pharmacological pain interventions in addition to PRN Hydrocodone-Acetaminophen. Review of the MAR showed that staff administered the PRN opioid on multiple occasions without any documented attempt to use non-pharmacological pain management beforehand, contrary to facility policy and the resident’s care plan. The CNO acknowledged that non-pharmacological interventions should have been offered prior to giving the hydrocodone but were not, resulting in inadequate pain management.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
Failure to Assess and Manage Pain After Unwitnessed Fall Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management and assessment for a severely cognitively impaired resident following an unwitnessed fall and subsequent onset of significant hip pain. The resident had a history of right femur fracture, osteoporosis, and dementia, and was admitted with an order for PRN acetaminophen 650 mg for unspecified pain. Prior to the incident, the resident required limited assistance with transfers, bed mobility, and toileting, used a wheelchair, and only occasionally had pain that rarely interfered with activities. On the date of the unwitnessed fall, there was no nursing progress note, no documentation of a fall, no assessment of the left lower extremity, and no assessment of changes in transfer, ambulation, or mobility, despite the nurse on duty documenting a pain level of 0. The nurse later stated he did not assess the resident for pain or range of motion and acknowledged the resident was cognitively impaired and had an impaired ability to request pain medication. Over the following days, multiple staff observed or were informed of the resident’s significant pain and changes in mobility, but assessments, documentation, communication, and pain management remained inadequate. During the night after the fall, another nurse documented that the resident was having “a lot of pain in her hip” and placed a note in the doctor’s book, but did not document a pain or head-to-toe assessment, did not administer PRN acetaminophen, and nevertheless recorded a pain score of 0 on the MAR. Nurse aides reported that the resident was screaming, crying, yelling out with transfers, unable to ambulate as before, and required care in bed due to pain with movement. One nurse documented, as a late entry, that the resident reported she had fallen the previous day and was screaming in pain when moved; this nurse contacted the NP, who stated the resident complained of pain all the time and instructed staff to give PRN acetaminophen and indicated he would evaluate the resident the next day. The late entry note did not document a pain level, a lower extremity assessment, or that the unwitnessed fall was communicated to the NP. The MAR showed PRN acetaminophen was given once and marked only as “slightly effective,” with no numerical pain monitoring, while pain scores of 0 continued to be documented on subsequent shifts despite ongoing pain behaviors. When the NP evaluated the resident, the chief complaint was hip pain, and nursing staff had reported that the resident was having pain. The NP documented that the resident was oriented to person only, had dementia and anxiety, appeared sleepy and groggy, and had non‑specific pain. The NP’s assessment did not include an examination of the lower extremities, and the plan was to treat presumed nerve and hip pain with PRN acetaminophen and to educate the resident to request pain medication, despite her severe cognitive impairment and inability to reliably rate or request pain. The NP later stated he was unaware of the fall and that, had he known, he would have ordered x‑rays immediately, and acknowledged that new onset severe pain should prompt imaging. Over the next several days, aides continued to observe the resident’s pain with transfers, ambulation, and repositioning, including wincing, grimacing, holding her hip, and needing increased assistance, but some aides did not report these findings to nurses, assuming the nurses were already aware. Nursing documentation remained sparse, with no progress notes on some days, inconsistent pain scores, limited use of PRN analgesics, and no thorough pain or mobility assessments recorded. Eventually, a nursing supervisor documented that the resident appeared to be in discomfort and verbalized hip pain, and mobile x‑rays were ordered. The progress note did not include a pain level or a detailed assessment of the left lower extremity. The x‑ray, completed days after the onset of severe pain, showed an acute displaced left femoral neck fracture. The following day, a nurse documented the x‑ray results and arranged for the resident’s transfer to the emergency department. At the hospital, the resident reported hip pain and was treated with IV hydromorphone, cyclobenzaprine, and acetaminophen, and underwent a left hip hemiarthroplasty without complications before returning to the facility. Throughout the period from the unwitnessed fall to the diagnosis of the fracture, the facility failed to ensure timely and thorough pain assessment, accurate pain documentation, effective communication of the fall and subsequent changes in condition to the NP and physician, and appropriate pain management for a resident who was unable to verbalize or request pain medication due to severe cognitive impairment. The DON stated that her expectation was that residents with pain would be thoroughly assessed regardless of cognitive status, that staff would monitor for pain and report increased pain or changes in condition to the physician, and that this resident was unable to rate or request pain and should have been assessed using non‑verbal indicators and provided pain medication as needed.
Failure to Implement Non-Pharmacologic Pain Interventions for Resident with Spinal Fracture
Penalty
Summary
The deficiency involves the facility’s failure to provide non-pharmacologic pain management interventions for a resident with acute pain related to a wedge compression fracture of the second lumbar vertebra. The resident’s MDS assessments documented moderately to severely impaired cognition, receipt of PRN pain medications, and use of non-medication pain interventions during one assessment period, but no scheduled or PRN pain medications and no non-medication pain interventions during a subsequent look-back period. The resident reported occasional pain with the worst pain rated as eight out of ten in the prior five days and received opioid medication during the seven-day look-back period. The care plan, revised 03/31/26, directed staff to use alternative pain management methods such as massage, aromatherapy, warm packs, and distraction, and the physician’s orders included PRN ibuprofen and hydrocodone-acetaminophen for pain. Despite these orders and care plan directions, observations showed the resident tearful, with clenched fists and facial grimacing while seated in the dining room, and again with facial grimacing and audible indicators of pain during a transfer from wheelchair to recliner requiring extensive assistance. The MAR documented pain scores ranging from one to seven, with staff administering ordered pain medications and documenting effective results, but there was no evidence that non-pharmacologic interventions were offered or implemented. CNAs interviewed stated the resident often complained of pain after a fall and had a lot of hip pain, and that nurses would give pain medication, but they were not aware of any non-pharmacologic pain interventions being used for this resident. An administrative nurse stated that, in addition to scheduled and PRN pain medications, staff were expected to attempt non-pharmacologic pain interventions and acknowledged the facility did not have an actual pain management policy, relying instead on a standard of care.
Failure to Implement Non-Pharmacological Interventions Prior to PRN Pain Medication
Penalty
Summary
Surveyors identified a deficiency in pain management when the facility failed to follow its Pain Assessment and Management policy, which required development and implementation of both non-pharmacological and pharmacological interventions to address pain. The care plan for Resident #53, who had diagnoses including acute osteomyelitis of the right ankle and foot and a lumbar vertebra fracture, documented that the facility would attempt non-pharmacological pain interventions as part of the treatment plan. Physician orders dated 2/11/26 and 3/20/26 authorized Hydrocodone-Acetaminophen 5-325 mg every four hours as needed. However, review of the MAR on 3/30/26 showed no documentation that non-pharmacological pain management was attempted prior to administering the PRN hydrocodone on multiple dates (3/17/26, 3/18/26, 3/20/26, 3/23/26, and 3/24/26). In an interview on 4/1/26, the CNO confirmed that non-pharmacological pain management should have been offered before administering the hydrocodone and that it had not been, resulting in the facility’s failure to provide adequate pain management for this resident. This failure created the potential for residents to experience continual pain and distress.
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
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