F0697

G

Failure to Assess, Treat, and Document Severe Pain for a Resident

Torrance, California Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide safe, appropriate pain management for a resident who repeatedly reported severe pain. The resident had multiple significant diagnoses, including irritable bowel syndrome, alcoholic cirrhosis with ascites, secondary esophageal varices, quadriplegia with contractures, and cervical disc disorder with myelopathy and spinal stenosis. Physician orders dated 6/9/25 directed staff to monitor the resident’s pain every shift using a 0–10 scale, administer acetaminophen 325 mg (two tablets) every six hours as needed for mild pain, and document non-pharmacologic interventions such as repositioning, relaxation breathing, and massage. An additional order dated 11/14/25 prescribed daily sublingual suboxone for pain management. The resident’s MDS showed intact cognition and total dependence on staff for mobility and ADLs.

On 11/21/25 at 2:59 p.m., nursing progress notes documented that the resident complained of severe pain rated 10/10 and had been vomiting for three days. Text messages between the RN supervisor and the NP that day showed the RN reporting sharp, stabbing abdominal and arm pain rated 10/10 and asking for pain management options. The NP responded with orders to use Tylenol suppository if available, warm compresses to the abdomen, and repositioning to reduce discomfort. Despite this, the pain assessment record showed no pain assessment documented on 11/21/25 after the 10/10 pain complaint, and the MAR for 11/21/25–11/22/25 indicated the resident did not receive suboxone as ordered. The RN supervisor later acknowledged there was no documentation of a pain assessment, no pharmacologic or non-pharmacologic interventions provided on 11/21/25, and that the NP’s text orders for non-pharmacologic interventions were not transcribed into the record or care plan.

Additional interviews and record reviews confirmed further lapses. A CNA reported the resident complained of severe abdominal pain on 11/22/25 and that a licensed nurse was notified, but there was no corresponding documentation of assessment or interventions. An LVN stated that on 11/21/25 the resident complained of abdominal pain, but he did not assess the pain’s location, level, or characteristics, did not obtain or record vital signs, did not document the complaint, and did not initiate monitoring despite recognizing this as a change of condition. The resident later reported that she experienced severe abdominal pain with vomiting blood starting on 11/20/25, that she was only given low-dose Tylenol which did not relieve her pain, and that staff refused to give her the sublingual pain medication for several days. The facility’s pain management and charting/documentation policies required systematic identification, assessment, treatment, evaluation of pain, development of an individualized IDT care plan, monitoring of effectiveness, documentation of non-pharmacologic interventions, and documentation of all services and changes in condition. These requirements were not followed for this resident, resulting in unaddressed severe pain and lack of an individualized pain management care plan.

The facility also failed to develop and implement an individualized care plan addressing the resident’s pain, despite ongoing pain complaints and existing orders for both pharmacologic and non-pharmacologic interventions. The RN supervisor confirmed that no care plan was created to address the resident’s pain and that the NP’s text orders for warm compresses, relaxation breathing, and repositioning were not incorporated into the care plan or progress notes. Pain assessments documented around the incident showed pain levels of 7/10 on 11/19/25 at 11:15 p.m., 0/10 on 11/21/25 at 4:42 a.m., 0/10 on 11/22/25 at 3:47 a.m., 0/10 on 11/23/25 at 4:15 a.m., and 8/10 on 11/23/25 at 7:35 p.m., but there was a clear gap on 11/21/25 after the documented 10/10 pain complaint. The combination of missing assessments, failure to administer ordered pain medication, failure to provide ordered non-pharmacologic measures, lack of documentation of NP orders, and absence of an individualized pain care plan constituted the deficient practice.

The deficient practices resulted in the resident experiencing severe sharp, stabbing arm and abdominal pain rated 10/10 for approximately 48 hours, requiring evaluation and treatment at a general acute care hospital. The resident reported feeling very stressed and frustrated and described the pain as the worst she had ever experienced. The RN supervisor acknowledged that failure to address the resident’s pain could affect the resident mentally and physically and potentially elevate blood pressure. The facility’s own policies on pain management and charting/documentation, which required comprehensive assessment, treatment, monitoring, and documentation of pain and changes in condition, were not followed in this case.