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F0697
D

Delay in PRN Pain Medication Administration for Hospice Resident

Green Bay, Wisconsin Survey Completed on 08-18-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident receiving hospice services, with diagnoses including lung cancer, brain cancer, COPD, and generalized anxiety disorder, did not receive prescribed PRN morphine for pain in a timely manner. The resident, who was cognitively intact, reported waiting approximately two hours for pain medication after requesting it. Staff interviews confirmed that there was a delay in administering the medication, as communication between nurses and CNAs was not effective, leading to the resident's request being overlooked until a CNA followed up. Documentation showed the resident had ongoing pain and discomfort, including issues with constipation, but the pain medication was not provided promptly as ordered. The facility's pain management policy required timely assessment and administration of pain medication, but this was not followed in the incident. The Assistant Director of Nursing was not initially aware of the delay, and the nurse responsible did not report the incident as required. The event was later identified through interviews and record review, confirming that the resident's pain management needs were not met according to policy and physician orders.

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