F0697

G

Failure to Implement and Follow Hospice Opioid Orders Resulting in Uncontrolled End‑of‑Life Pain

Steubenville, Ohio Survey Completed on 01-05-2026

Penalty

No penalty information released

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.