Failure to Implement and Follow Hospice Opioid Orders Resulting in Uncontrolled End‑of‑Life Pain
Summary
The deficiency involves the facility’s failure to implement an effective pain management program for a hospice resident with chronic and end‑of‑life pain, including failure to timely implement and consistently administer ordered opioid medications. The resident had extensive diagnoses including chronic pain syndrome, Parkinsonism, osteoarthritis, neuropathy, prior shoulder replacement, cerebral infarction, and was receiving hospice services for terminal care. The care plan identified the resident as at risk for pain and chronic pain, with interventions to administer pain medications as ordered, monitor for effectiveness and side effects, observe for non‑verbal signs of pain, and notify the physician or hospice for breakthrough pain. The resident’s hospice plan of care included multiple analgesics (Lidocaine patch, Gabapentin, Ibuprofen, Tylenol, and Oxycodone) and recognized that the resident grimaced with movement and had constant pain despite scheduled medications. Hospice recommended increasing Oxycodone to every eight hours scheduled and every four hours as needed, with Zofran as needed, and the physician approved these changes. However, the new Oxycodone and Zofran orders dated one day were not implemented in the facility’s record until three days later at 7:43 p.m., despite narcotic control documentation showing the Oxycodone order had been received earlier. During this period, there was no evidence in the medical record that the new dosing regimen was in place. Additionally, the MAR showed that scheduled Oxycodone doses at 10:00 p.m. and 6:00 a.m. on two consecutive days were not administered because the resident was sleeping, even though the narcotic control sheet showed a 10:00 p.m. dose signed out without documentation of waste. There was also no evidence that as‑needed Oxycodone was administered over several days, despite the resident’s known chronic and hospice‑related pain and staff‑documented non‑verbal indicators of pain on the MDS. Further documentation showed ongoing inconsistencies and omissions in opioid administration and order management. Progress notes indicated that the resident’s pain had been well controlled when all scheduled Oxycodone doses were given, and that missed 2:00 a.m. doses (charted as not given because the resident was sleeping) and changes in the pain regimen were associated with increased pain noted by hospice. There was confusion between Oxycodone and Morphine orders, including a hospice order for Morphine solution as needed without clear discontinuation of Oxycodone, and later notes indicating that Oxycodone should have been continued until Morphine was started, resulting in missed Oxycodone doses. MARs and narcotic control sheets did not match for Oxycodone 5 mg and 10 mg, with doses documented as given on the MAR but not signed out on narcotic logs, and the DON confirmed there were no narcotic control records to support certain documented administrations. Hospice notes and interviews described the resident exhibiting non‑verbal signs of pain and distress (anxiety, crying, moaning, fidgeting, yelling, smacking, kicking, and tense posture), and staff and family reported that at least one nurse did not administer pain medication per hospice orders, sometimes stating the resident did not need it or was fine because she was sleeping. The surveyors concluded that these failures resulted in uncontrolled pain at end of life and required escalation and changes in the resident’s pain regimen to regain control. Additional information in the record showed that the resident’s daughter repeatedly voiced concerns that pain medications were not being administered when the resident was sleeping and that she wanted her mother awakened to receive ordered pain medication. A guest satisfaction concern form documented the daughter’s complaint that a nurse was not giving pain medication when the resident was sleeping, and anonymous staff interviews confirmed that the daughter was upset because a nurse did not administer medications per hospice orders and did not believe in hospice. The facility’s own soft file and corporate review acknowledged family concerns about pain management, and hospice documentation noted that a previous Oxycodone order had not been placed in the resident’s orders, resulting in the resident not receiving it until hospice intervened to have it added back. The DON and Administrator confirmed delays in implementing hospice orders, missed scheduled Oxycodone doses due to the resident sleeping, confusion over concurrent Oxycodone and Morphine orders, and lack of narcotic control documentation to support certain MAR entries. The surveyors determined that these actions and inactions constituted a failure to provide safe, appropriate pain management for a resident requiring such services, resulting in actual harm in the form of uncontrolled end‑of‑life pain. The record also referenced another resident who had concerns that pain medication was not provided upon request in a timely manner, though this concern was not incorporated into the facility’s investigation of pain management issues. The facility’s pain management policy stated that residents’ pain would be evaluated and identified, including in residents with dementia who cannot verbalize pain, and that behaviors such as calling out, facial expressions, refusing to eat, striking out when moved, or increased confusion could indicate pain. Despite this policy, the documentation for this hospice resident showed repeated non‑verbal signs of pain and family reports of suffering, alongside missed or delayed implementation of opioid orders, inconsistent documentation between MARs and narcotic logs, and staff decisions not to administer ordered opioids when the resident was sleeping. These documented events formed the basis of the cited deficiency for failure to provide safe, appropriate pain management.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with osteoarthritis, chronic neck and arm pain, and intervertebral disc degeneration did not consistently receive ordered pain management interventions. The care plan and physician orders called for daily application of a warm neck wrap with skin checks and scheduled tramadol doses, as well as PRN hydrocodone-acetaminophen every 8 hours. Documentation showed multiple missed neck wrap applications and several missed tramadol doses, and one instance where hydrocodone-acetaminophen was administered twice within 1.5 hours instead of at the ordered 8-hour interval. The resident reported significant pain and difficulty getting staff to administer pain medications as needed, while facility policy required adherence to the 10 Rights of medication administration, including right dose and right time/frequency.
A resident with extensive traumatic fractures, internal injuries, and a long history of chronic pain management was admitted on existing orders for ibuprofen PRN and Percocet for pain, with hospital discharge instructions indicating scheduled Percocet three times daily. During the first night after admission, staff administered only ibuprofen, documented as ineffective, and did not provide any Percocet because the hospital had not sent written narcotic prescriptions and the DON did not obtain a timely verbal order to access Percocet from the emergency kit. The resident repeatedly complained of severe, escalating pain, used the call light frequently, yelled out, and ultimately called 911, signed out AMA, and was transported to the ED, where she reported uncontrolled pain and opioid withdrawal symptoms and received Percocet.
A resident with chronic pain from degenerative disc disease and avascular necrosis experienced repeated episodes of uncontrolled pain, with scores up to 10/10, despite ongoing adjustments to analgesic medications. The care plan focused on pharmacologic interventions and monitoring but did not include any non-pharmacological pain management strategies, even as pain remained only partially controlled. Staff interviews revealed that some staff avoided the resident due to perceived rude behavior, the resident frequently refused care and appointments because of pain, and the resident requested increased narcotics and medical marijuana. The MDS coordinator stated that ineffective interventions should be revised, yet the care plan was not updated to add alternative or non-pharmacologic approaches, contrary to the facility’s own pain management policy requiring care consistent with professional standards and resident goals and preferences.
A resident with multiple pain-related conditions, including neuropathy, fracture, and chronic wounds, had care plans and PRN orders for various analgesics and non-pharmacological interventions, but the plan did not specify an acceptable pain level or clearly direct which analgesic to use before wound treatments. Records showed no comprehensive assessment or specific interventions for preventing pain during wound care, and on one morning only aspirin was given despite a documented pain level of 6, with no evidence that other ordered PRN pain medications or non-pharmacological measures were offered. During an observed buttock dressing change, the resident repeatedly yelled and verbalized pain while being turned and treated, and pain medication was not offered before the procedure began. Staff interviews confirmed the resident frequently screamed in pain with repositioning, that PRN medications were often given only if requested or directed, and that the LPN and DON later acknowledged that stronger pain medication and earlier intervention should have been used based on the facility’s pain scales and the resident’s reported pain levels.
A resident with migraines and chronic pain did not receive timely pain management after repeatedly reporting a migraine and appearing in visible distress. An NA notified an LPN, an RN said she could not access the med cart, and the resident continued waiting while the LPN was off the unit; the PRN migraine medication was not given until 40 minutes after the first complaint. The DON acknowledged the resident should not have waited that long for pain medication.
A resident with lupus and chronic pain repeatedly pressed her call light, cried out in pain, called 911 twice, and pulled the fire alarm while asking to go to the hospital. The record showed required pain checks were not documented on consecutive days, and staff interviews indicated the resident’s distress was treated as behavior rather than as pain needing prompt assessment and response.
Failure to Follow Ordered Pharmacologic and Non-Pharmacologic Pain Management
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pharmacological and non-pharmacological pain management for a resident with chronic pain. The resident, who was cognitively intact and had diagnoses including osteoarthritis, low back pain, bilateral arm pain, and intervertebral disc degeneration, reported significant pain in her right arm and shoulder and difficulty getting staff to administer pain medications as needed after a recent schedule change. Her care plan, revised on 4/30/26, identified neck pain due to osteoarthritis and included interventions such as medications and a warm neck pack as ordered. A physician’s order directed nursing staff to apply a warm neck wrap daily for 20 minutes with skin checks before and after application, but the April 2026 Treatment Administration Record showed the neck wrap was not documented as administered on multiple specified dates. The resident also had multiple physician orders for pain medications that were not followed as written. An order dated 4/9/26 for hydrocodone-acetaminophen 5-325 mg, one tablet by mouth every 8 hours as needed, was documented on the April 2026 Medication Administration Record as being given at 8:00 p.m. and again at 9:30 p.m. on the same day, which did not comply with the ordered 8-hour interval. Another order dated 4/14/26 for tramadol 50 mg by mouth four times a day was not documented as administered at several scheduled times throughout April, including missed doses on multiple mornings, noons, and evenings. During an interview, the DON stated she had no further information to provide. The facility’s own medication administration policy required adherence to the “10 Rights” of medication administration, including right dose and right time/frequency, and checking the MAR and physician’s orders before medicating.
Failure to Provide Ordered Opioid Analgesia for Resident With Severe Traumatic Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered opioid pain medication to a newly admitted resident with extensive traumatic injuries and a history of chronic pain management. The resident was admitted following a serious motor vehicle accident that resulted in multiple fractures (thoracic vertebrae, ribs, pelvis, sacrum, humerus, ilium), lung contusions, traumatic pneumothorax, liver and spleen lacerations, and hemoperitoneum. Hospital documentation showed that prior to admission the resident had been on Percocet 5-325 mg three times daily as an outpatient and was discharged from the hospital with instructions to continue Percocet 5-325 mg one tablet three times daily (scheduled) and ibuprofen 800 mg every 8 hours as needed for pain. The facility’s physician orders on admission included ibuprofen 800 mg every 8 hours as needed and Percocet 5-325 mg every 8 hours as needed for pain. On the evening and night following admission, the facility administered only ibuprofen and did not provide any Percocet, despite the resident’s repeated complaints of severe pain. The MAR documented that ibuprofen 800 mg was given late in the evening for a pain level of 4 and was noted as ineffective in controlling the pain, with no documentation that Percocet was ever administered. The DON documented that the hospital had not sent written prescriptions (“hard scripts”) for the narcotic pain medication, that the pharmacy reported not receiving such scripts, and that the facility was unable to access narcotics from the emergency kit without a prescription. The DON contacted the pharmacy and the hospital but did not obtain an order that would allow access to Percocet from the emergency kit, and she did not contact a provider at the time she first realized the resident had arrived without the necessary narcotic prescriptions. The DON later stated she was not aware that a verbal order could have been used to access the emergency kit and acknowledged there was a discrepancy between the facility’s PRN Percocet order and the hospital’s scheduled Percocet order, of which she had not been aware. Throughout the night, the resident continued to report uncontrolled pain, which she later described as escalating to 10/10, and she reported yelling out in pain and repeatedly requesting Percocet. CNAs reported that the resident was constantly on the call light, complaining about needing pain pills, threatening to sign out AMA, and yelling out. The DON documented that the resident complained of pain and inability to sleep, had received PRN ibuprofen, and that vital signs were within normal limits; she also noted that the resident had two loose stools but did not associate them with opioid withdrawal. The pharmacy director confirmed that the correct dose of Percocet was available in the emergency kit and that it could have been accessed with a provider’s emergency verbal order. The medical director stated that, had he been contacted sooner, he could have given a verbal order to access Percocet from the emergency kit or ordered transfer to the ER. Instead, after the resident called 911 requesting transport for pain management, the medical director eventually ordered transfer to the ER at the resident’s request, and the resident signed AMA paperwork stating she would not return. In the ER, the resident presented with complaints of pain all over, nausea, vomiting, diarrhea, and reported opioid withdrawal symptoms, with documentation that no pain medication had been administered between the time of admission to the facility and arrival at the ER, approximately 12 hours later. The ER administered Percocet and discharged her with a prescription for Percocet. The facility’s own pain management policy stated that it was the policy of the facility to respect and support the resident’s right to optimal pain assessment and management, and referenced an opioid use policy and procedure. Despite this, the record shows that the facility did not provide the ordered opioid medication, did not resolve the lack of a written prescription in a timely manner through available mechanisms (such as obtaining a verbal order to access the emergency kit), and did not adjust its actions when ibuprofen was documented as ineffective. The combination of the resident’s extensive injuries, documented chronic pain management history, hospital discharge instructions for scheduled Percocet, and the facility’s failure to administer any Percocet or secure timely prescriber authorization led to the resident experiencing uncontrolled pain, reporting opioid withdrawal symptoms, and ultimately signing out AMA and calling 911 for transport to the ER for pain management.
Failure to Provide Effective, Multimodal Pain Management
Penalty
Summary
Facility staff failed to ensure effective pain management for a resident with chronic pain syndrome related to degenerative disc disease of the lumbar spine and avascular necrosis of the left hip. The resident’s care plan identified bilateral hip pain and neuropathic pain, with goals for the resident to verbalize relief of pain, cope with and complete activities with pain relief, and remain free from interruption in normal activities due to pain. Interventions in the care plan focused on administering analgesics as ordered, anticipating the resident’s need for pain relief, responding promptly to complaints of pain, and evaluating the effectiveness of pain interventions, including reviewing compliance, symptom alleviation, dosing schedules, resident satisfaction, and impact on function and cognition. However, the care plan, initiated in April 2024 and last revised in December 2025, did not include any non-pharmacological interventions to assist with alleviating the resident’s pain. Clinical record review showed multiple episodes of uncontrolled pain despite ongoing pharmacologic management. A nursing note documented that staff were called to the resident’s room for increased, uncontrolled pain with a reported pain score of 10/10, and the physician assistant provided a one-time order for hydrocodone/acetaminophen 10-325 mg. Subsequent progress notes indicated chronic pain syndrome with ongoing symptom review and pain described as only partially controlled, with continued reports of uncontrolled pain and pain ratings up to 10/10. Although analgesic dosages were adjusted over time, there was no evidence in the record that non-pharmacological or alternative pain management approaches were implemented or documented to help alleviate the resident’s pain. Staff interviews further illustrated issues with the resident’s pain management and staff response. An LPN reported that the resident was sometimes rude and disrespectful, and stated that staff ignored and avoided the resident’s room because of how he spoke to people. The assistant DON reported that the resident refused care daily due to pain, screamed out when his left leg was moved, and declined care, assistance, and appointments because of pain, while also requesting increased pain medication dosages and medical marijuana. The MDS coordinator explained that care plans should be updated with changes in condition or ineffective interventions, and that interventions should be changed if not effective, but there was no indication that non-pharmacological interventions were added to the care plan despite ongoing uncontrolled pain. The facility’s own pain management policy required pain management consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident’s goals and preferences, but documentation and interviews showed that non-pharmacological pain interventions were not developed or implemented for this resident.
Failure to Individualize and Provide Adequate Pain Management During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement an individualized pain management plan for a resident with multiple pain-related diagnoses, particularly in relation to wound treatments and repositioning. The resident had documented conditions including polyneuropathy, a left femur neck fracture, polyosteoarthritis, chronic pain related to absence of toes on both feet, and gastroesophageal reflux disease. The admission MDS showed mild cognitive impairment, verbal behaviors, and rejection of care on some days. Care plans identified use of aspirin therapy and opioid pain medication related to fracture, with goals to avoid discomfort and adverse side effects, and interventions to administer analgesics as ordered, monitor side effects and effectiveness, and assess pain on a 0–10 scale. However, the care plan did not identify the resident’s acceptable level of pain, and while a pressure wound care plan stated to treat pain per orders prior to treatment/turning, there was no corresponding physician order specifying which analgesic to use or when to administer it before wound care. The resident’s physician orders included aspirin 81 mg daily, PRN acetaminophen 1,000 mg every 6 hours for moderate pain, PRN gabapentin 600 mg every 8 hours for pain, and PRN oxycodone 5 mg every 4 hours for severe pain, with a maximum daily dose. The MAR listed non-pharmacological interventions such as ice, distraction, and rest, with instructions to document effectiveness and non-pharmacological measures used alongside medications. Record review showed no comprehensive assessment, treatment orders, or care plan interventions specifically addressing pain prevention during wound treatments. On one morning, the MAR documented administration of aspirin with a recorded pain level of 6, but there was no indication that non-pharmacological interventions were offered or that PRN acetaminophen, gabapentin, or oxycodone were offered or administered at that time. During an observed dressing change to the resident’s buttocks, the resident repeatedly yelled out, stated he was cold and hurting, and vocalized pain while being turned and while the wound was cleaned, using exclamations and profanity. The LPN performing the dressing change did not offer pain medication before starting the procedure and acknowledged that the dressing change had already begun and that pain medication should perhaps have been given beforehand, noting the resident was in pain every time he was turned. Staff interviews indicated the resident screamed in pain whenever turned or repositioned, and that this was reported to nurses and TMAs. A TMA reported she only administered PRN pain medication if a resident asked or a nurse instructed her, and during the morning pass she gave aspirin and recorded a pain level of 6 without notifying the LPN; the resident did not request additional pain medication at that time. The LPN later stated that, based on the resident’s pain level and the facility’s FACES and numeric pain scales, oxycodone should have been used for severe pain, and the DON stated the resident should have been offered pain medication when pain was identified at 6 and that the dressing change should have been stopped when the resident voiced pain. These findings show the facility did not individualize and implement pain management for wound care and did not provide adequate pain control during the observed treatment.
Delayed Pain Medication for Resident with Migraine
Penalty
Summary
Safe, appropriate pain management was not provided for Resident ID #17, who was admitted with diagnoses including migraines and chronic pain. The resident’s care plan dated 4/20/2026 included a goal for the resident to verbalize adequate pain relief and an intervention to respond immediately to any complaint of pain. The physician ordered Butalbital-APAP-Caffeine 50-300-40 mg, 1 capsule every 12 hours as needed for migraine pain. On 4/29/2026 at 10:30 AM, the resident was observed in the hallway complaining of a migraine, moaning in pain, and holding his/her head. At 10:34 AM, an NA reported to an LPN that the resident wanted pain medication, and at 10:37 AM the resident continued to complain of migraine pain and told an RN about the pain, but the RN stated she did not have keys to the medication cart and could not get any pain medication. The resident continued to complain of severe head pain, returned to the room to lie down at 10:40 AM, and the LPN was still off the unit at 10:42 AM. The resident was not assessed when the LPN returned, and the medication was not administered until 11:10 AM, 40 minutes after the initial complaint. The resident later reported pain rated 7 out of 10, and the DON acknowledged that a resident should not wait 40 minutes for pain medication.
Failure to Address Resident Pain and Requests for Help
Penalty
Summary
The facility failed to provide safe, appropriate pain management for a resident with lupus, epilepsy, anxiety, obesity, joint pain, stiffness, muscle wasting and atrophy, and cognitive communication deficit. The resident’s care plan identified her as at risk for pain and discomfort related to lupus, and she had standing and newly added pain-related orders, including scheduled acetaminophen-codeine and gabapentin, along with an order for a lumbar spine x-ray after she reported pain. On 03/04/2026, the resident repeatedly sought help during the early morning hours. The report states she pressed her call light, cried out in pain, called 911 twice, and pulled the fire alarm while requesting to go to the hospital. A roommate stated the resident woke up crying in pain around 4:00 a.m., called the facility front desk from her cellphone, and called 911 again after staff responded. The roommate also stated the resident continued yelling for assistance until about 5:00 a.m., when staff got her out of bed and into a wheelchair, and later returned her to bed after the fire alarm was activated. The resident’s record showed pain monitoring was required every shift using a 0-10 scale, but no pain levels were recorded on 03/03/2026 or 03/04/2026. The record also showed that after the resident reported pain, a nurse completed a pain evaluation and medication was administered, and later that day the MD documented severe, sharp pain that was worse than usual and ordered additional pain treatment and imaging. Staff interviews reflected that the resident’s calls to 911 were treated as behavior rather than as pain-related distress, and one nurse stated she told 911 the resident was fine and removed the resident’s cellphone. The report states the facility failed to monitor and address the resident’s pain during the period when she was repeatedly seeking help and requesting hospital transfer.
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