F0655

D

Failure to Complete Baseline Pain Management Care Plan for Hospice Resident

Garland, Texas Survey Completed on 01-05-2026

Penalty

Fine: $143,455

Summary

The deficiency involves the facility’s failure to develop and implement a baseline care plan within 48 hours of admission that addressed a hospice resident’s significant pain management needs. The resident, a middle‑aged female with metastatic malignant neoplasms of the right breast, liver, intrahepatic bile ducts, and bone, as well as chronic pain and depression, was admitted for respite care and then remained at the facility. Record review showed that the resident’s baseline care plan had been started but not completed, and it contained no information about her pain or hospice services. The facility’s own policy required person‑centered baseline care plans to be developed and implemented within 48 hours of admission, including measurable objectives to meet the resident’s medical, nursing, mental, and psychosocial needs.

Clinical documentation and observations showed that the resident had ongoing, severe pain that was not effectively addressed in a care plan. An initial pain assessment documented non‑verbal indicators of pain, including occasional labored breathing, repeated troubled calling out, loud moaning or groaning, crying, facial grimacing, tense body language, and a pain score of 6 with generalized body pain, while the resident’s acceptable pain level was recorded as 0. Progress notes from admission described the resident as confused, disoriented, crying, restless, and unable to control her body, with hospice already involved and the facility physician agreeing to continue hospice orders. Despite this, there was no completed baseline care plan outlining pain management interventions or coordination with hospice services.

Surveyor observations and staff and family interviews further demonstrated that the resident exhibited persistent signs of severe pain over multiple days without a guiding baseline care plan. On multiple observations, the resident was seen thrashing, writhing, moaning, crying, grimacing, and screaming during movement and incontinent care, with symptoms worsening on touch or repositioning. Nursing staff reported that the resident “was always crying,” that morphine given as needed every 1–2 hours did not appear effective, and that she would only sleep briefly before waking and resuming moaning and crying. CNAs described frequent crying, screaming, restlessness, and grimacing, and reported uncertainty about the source of pain and the effectiveness or timing of medications. Family members stated the resident had been in pain during each visit, believed her pain was not being managed, and reported that staff often only glanced into the room rather than performing full assessments. Multiple nurses, ADONs, the DON, and the Administrator all acknowledged in interviews that pain should have been included in the baseline care plan, that the resident’s baseline care plan was not completed, and that its absence meant staff did not have a defined plan of care or interventions for managing the resident’s pain.

The facility’s leadership and nursing staff confirmed that the baseline care plan for this resident was not triggered or completed when she was admitted for respite care and that pain management was not care planned despite her known metastatic cancer and documented severe pain. Staff interviews consistently indicated that baseline care plans are supposed to be completed on admission by the admitting nurse, that pain must be included when present, and that these plans guide staff on how to care for residents, including when and how to address pain. In this case, the lack of a completed baseline care plan with pain interventions and hospice coordination resulted in staff relying on PRN medications without a structured, person‑centered plan, while the resident continued to display ongoing, excruciating pain over the period reviewed.