F0697

E

Failure to Provide Consistent, Properly Documented Pain Management and Controlled Drug Administration

Grand Haven, Michigan Survey Completed on 02-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and to administer controlled pain medications according to provider orders and residents’ goals and preferences. One cognitively intact female resident with acute and chronic respiratory failure with hypoxia, spinal stenosis, low back pain, and asthma had scheduled hydromorphone and methocarbamol ordered every six hours and four times a day, respectively. She reported that on a night when an agency LPN was working, she did not receive her scheduled midnight and early morning pain medications, despite the Medication Administration Record (MAR) and Controlled Substance Proof of Use forms indicating they were given. She stated the LPN attempted to give her medications early around 9:30 PM, claimed her pain pill and muscle relaxer were in the cup, but she did not see them, shook the cup, and believed they were not present. She later reported increased and lingering pain due to not receiving her medications.

The facility’s own incident report and staff statements showed discrepancies between documentation and actual access to narcotics. The LPN reported to the oncoming RN and the DON that he had locked the narcotic and med-cart keys in the medication room during the night and did not regain access until after 6:40 AM, which would have prevented timely administration of scheduled narcotics, including the resident’s 6:00 AM hydromorphone. He also told the off‑going RN that he had “prepped all his narcs,” indicating he removed doses and documented them on Proof of Use sheets at the beginning of his shift rather than at the actual time of administration. The DON documented that the LPN later admitted he did not properly document medications he administered and that narcotics were administered late once access to the keys was restored. A regional clinical nurse observed that the LPN did not initially follow required controlled substance count procedures and needed direction to complete them correctly, and a colleague described him as a sloppy nurse with poor practices.

Additional record review identified further failures in pain and controlled medication management for other residents. One male resident with hypertensive heart and chronic kidney disease with heart failure had an ordered three‑times‑daily hydrocodone‑acetaminophen regimen; on one date, the afternoon dose was neither dispensed on the Controlled Substance Proof of Use form nor documented as given on the MAR, and there was no documentation explaining the omission. Another male resident with lumbar inflammatory spondylopathy had hydrocodone‑acetaminophen ordered three times daily; on one date, the morning dose was not dispensed per the Proof of Use form, yet all three doses were documented as administered on the MAR, with no documentation of withholding. A female resident with neuropathy had pregabalin ordered three times daily; on one date, the afternoon dose was not dispensed per the Proof of Use form and was left blank on the MAR, again with no documentation for withholding. During a resident group meeting, multiple residents reported that medications, including scheduled and PRN pain medications, were not always administered on time, that staff were confrontational when concerns were raised, and that some residents had to attend therapy without timely PRN pain medication, with several residents specifically citing problems with a male nurse not administering pain medications on time or at all.

Facility policies required staff to prepare medications for only one resident at a time, to document removal of controlled substances on Proof of Use sheets as soon as the medication is removed, and to document administration on the MAR or eMAR only after the medication is actually given, with the MAR/eMAR serving as the record of administration. The policies also required proper shift‑to‑shift narcotic counts with both on‑going and off‑going nurses. The nursing textbook cited in the report reinforces that medications should never be documented as given until after administration. The events described, including pre‑prepping narcotics, documenting doses as given when access to narcotics was unavailable, missing doses without explanation, and inconsistent documentation between Proof of Use forms and MARs, demonstrate that these standards and policies were not followed, resulting in missed, late, or unverified pain medication administration for multiple residents.

During the confidential resident group meeting, one resident reported that scheduled pain medications were passed late and PRN pain medications were not promptly administered when requested, sometimes taking more than an hour. Three residents reported they had not received pain medications in the past and had reported these issues to management. One resident described having to receive therapy services without PRN pain medication, making participation difficult due to pain. Several residents reported prior problems with a male nurse not administering pain medication on time or at all, and they noted that this nurse was no longer working at the facility. These resident reports, combined with the documented discrepancies in controlled substance handling and administration records, support the finding that the facility failed to ensure consistent, timely, and properly documented pain management services for residents who required such care.