F0697

K

Failure to Provide Effective Hospice Pain Management for Terminal Cancer Resident

Garland, Texas Survey Completed on 01-05-2026

Penalty

Fine: $143,455

Summary

The deficiency involves the facility’s failure to provide effective pain management to a hospice resident with end‑stage metastatic cancer to the breast, liver, bone, and intrahepatic bile ducts. On admission for respite care, the resident was confused, disoriented, crying, and restless, and an initial pain assessment documented non‑verbal indicators of pain, including loud moaning or groaning, crying, facial grimacing, tense body language, and a pain score of 6, with an acceptable pain level of 0. The resident was started on morphine sulfate oral solution with an order for 0.25 mL every two hours PRN for shortness of breath and pain, later changed to a routine schedule and then back to PRN with a range dose of 0.25–1.0 mL every hour. Despite these orders, the facility did not complete a finished baseline care plan or comprehensive care plan for the resident, and the existing care plan only addressed impaired communication without specific pain management interventions.

From admission through the identified period, the resident exhibited persistent and severe non‑verbal signs of pain, including thrashing and writhing in bed, crying, moaning, groaning, screaming during incontinent care, facial grimacing, clenched jaw, and inability to be consoled or respond to questions. Observations on multiple occasions showed the resident becoming more distressed with movement and care. CNAs reported that the resident was always crying, screaming during changes, restless, and grimacing, and they notified nursing staff of these signs. Family members also reported that the resident had been in pain every time they visited, that she had stage 4 cancer, and that she had not been comfortable since arriving at the facility. One family member stated staff only glanced into the room rather than performing full assessments and expressed that the resident’s pain was not being managed.

Nursing staff acknowledged that the resident’s behaviors indicated pain and that the morphine doses being given were not effective. The LVN caring for the resident stated that the current morphine order allowed 0.25–1.0 mL every hour PRN, but he consistently administered only 0.25 mL, later 0.5 mL, despite ongoing severe pain behaviors, and documented these doses only in the narcotic log rather than on the MAR. He reported assessing the resident’s pain every 30–60 minutes but did not chart these assessments, and the EHR contained no pain assessments during this period. The MAR showed no breakthrough or long‑acting pain medications, and there was no documentation that the physician or hospice was notified when the resident displayed uncontrolled pain. The DON and hospice staff confirmed that the resident’s pain was severe and ongoing, that the morphine order had been changed to PRN partly in response to a non‑POA friend’s concerns about sedation and eating, and that staff and hospice had been influenced by this friend’s wishes rather than consistently prioritizing the resident’s comfort. These actions and omissions resulted in the resident experiencing prolonged, uncontrolled pain and led surveyors to identify immediate jeopardy related to pain management.

The facility’s own pain management policy required assessment for pain upon admission and with changes in condition, establishment of pain management goals, individualized interventions, ongoing monitoring of response to pharmacologic and non‑pharmacologic measures, and reporting to the physician of patient response to interventions. The hospice coordination policy required a coordinated plan of care, directives for managing pain and uncomfortable symptoms, monitoring and evaluation of the resident’s response to hospice care plans, and immediate communication with hospice and the attending physician regarding significant changes or emergent situations. In this case, the facility did not complete or implement a comprehensive, individualized pain management plan, did not consistently assess and document pain or reassess after interventions, did not fully utilize the ordered morphine range to address uncontrolled pain, and did not document timely escalation to hospice or the physician when pain remained severe. These failures, in the context of the resident’s terminal cancer and clear non‑verbal signs of excruciating pain, constituted the cited deficiency in pain management.

Removal Plan

• Charge Nurse/DON/designee assessed the resident’s pain using an appropriate tool (0-10 scale if able; PAINAD/non-verbal tool if unable) and documented signs/symptoms and current comfort level.
• Facility contacted the hospice nurse and attending/medical provider to report uncontrolled pain episodes and frequency of distress behaviors.
• Facility obtained clarified, complete medication orders from prescriber/hospice that include clear administration parameters (e.g., which dose to give under which conditions) and documented these orders per policy.
• Facility updated the care plan to reflect end-of-life comfort needs, pain assessment frequency, medication administration/reassessment expectations, and hospice coordination.
• Facility implemented enhanced monitoring until pain was controlled, including pain checks and comfort rounds at least hourly, with reassessment after each intervention and documentation of effectiveness.
• DON/designee ran a list of all residents on hospice and all residents with active opioid PRN range orders and/or recent pain complaints.
• For each identified resident, a licensed nurse/designee audited for complete parameters on PRN/range orders (no range without direction), pain assessment and reassessment documentation after PRN administration, evidence of provider/hospice notification for uncontrolled pain, and care plan alignment with pain management needs.
• Any orders lacking parameters were held for clarification; the facility contacted the provider/hospice promptly and residents were assessed and managed per hospice/provider direction.
• Facility implemented a requirement to not accept or implement range/variable dose opioid orders without written parameters from prescriber/hospice (dose selection criteria, frequency limits, reassessment expectations, and hold criteria).
• Orders missing parameters triggered an automatic provider/hospice clarification call and documented follow-up.
• Facility implemented an uncontrolled pain escalation pathway requiring staff to notify hospice/provider when pain is not relieved or distress behaviors persist, using defined escalation triggers (e.g., repeated PRN use, persistent severe pain behaviors, frequent crying/screaming).
• For hospice residents, facility implemented use of a Hospice Symptom Escalation Call Log to document time of call, who was contacted, response received, and new orders.
• Facility implemented documentation standards requiring pain documentation every shift and with any complaint/behavior suggestive of pain, before PRN administration (baseline), reassessment after medication/intervention within policy timeframe, documentation of effectiveness, and documentation of escalation if ineffective.
• Facility provided staff education/competency training for all licensed nurses (and individualized education for those who missed the in-service) on pain assessment including non-verbal tools, end-of-life comfort care expectations and SNF/hospice coordination, PRN opioid documentation and reassessment standards, and clarifying incomplete orders/range dose parameters, with sign-in sheets and a post-test prior to assuming duties.
• Facility implemented audits/monitoring using a Pain Management & Hospice Coordination Audit tool to monitor PRN opioid/range order parameters, pain assessment documentation, reassessment after each PRN, hospice/provider notification when pain uncontrolled, and care plan alignment with pain/hospice involvement.
• Facility set audit frequency to weekly for 4 weeks, then monthly for 2 months, then quarterly, with DON/ADON/designee and unit managers responsible for follow-up and results reviewed in QAPI with trends/actions documented.
• QAPI committee provided oversight to review audit results, identify patterns (e.g., missing parameters, missed reassessments, delays calling hospice/provider), and implement additional actions (targeted re-education, disciplinary action if warranted, EMR prompts, staffing workflow changes).