F0656

D

Failure to Include PRN Pain Management in Comprehensive Care Plan

Lampasas, Texas Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan that included measurable objectives and timeframes for a resident’s identified pain management needs. An older female resident with diagnoses including heart failure and unspecified dementia was admitted and later readmitted to the facility. Her MDS, completed on 12/22/25, showed a BIMS score of 99, indicating the exam could not be completed, and documented that she received PRN pain medications. The resident’s order summary showed a PRN order for Tramadol 50 mg by mouth every 6 hours as needed for pain, with a start date of 12/01/25. However, review of the resident’s care plan, last revised on 11/10/25, revealed no mention of pain, pain-related issues, or pain medication, despite the active PRN Tramadol order and the MDS coding for PRN pain medication use.

During interviews, the resident was unable to recall which medications she received and had difficulty answering questions. Multiple staff members, including an LPN, LVNs, the DON, a CNA, and the administrator, acknowledged that the resident’s pain and PRN Tramadol should have been included in the care plan and that nurses are responsible for updating care plans when there are changes. Staff also reported that PRN pain medications were not typically included in care plans and that there was no current MDS coordinator, with a corporate nurse assisting and LVN B having last assisted with MDS duties until 12/23/25. The facility’s undated policy on comprehensive care planning states that each resident will have a person-centered comprehensive care plan developed and implemented to meet medical, physical, mental, and psychosocial needs identified in the comprehensive assessment, but this was not followed for this resident’s pain management needs.