F0697

D

Failure to Collaborate With Hospice and Fully Utilize Ordered Analgesics for Severe Pain

Oshkosh, Wisconsin Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate pain management to a hospice resident with metastatic prostate cancer, a stage 4 heel pressure ulcer, osteomyelitis, chronic pain, peripheral neuropathy, cervical radiculopathy, and opioid dependence. The resident had moderate cognitive impairment and an activated healthcare power of attorney. Facility policy required systematic recognition, assessment, treatment, and monitoring of pain, including use of appropriate pain assessment tools, observation of non-verbal indicators, collaboration with the prescriber and hospice, and reassessment and adjustment of medications when pain was not controlled. On the night shift prior to the event, the resident’s pain was documented as 0, but on the following morning shift the pain level was documented as 10 out of 10.

On the morning in question, CNAs reported that the resident repeatedly requested pain or gas medication, was rude and demanding, and later was found balled up and non-verbal. Another CNA reported the resident stated they were waiting for pain medication, continued to report severe pain, refused breakfast, and declined non-pharmacological interventions such as an ice pack and repositioning. The DON stated the resident refused assessments on admission and again that morning, while reporting pain at 10 out of 10. The DON also stated that the assigned RN had provided all pain medication the resident could receive and that the pain remained at 10 out of 10, leading to a decision to send the resident to the ER for intractable, uncontrolled pain. However, review of the MAR with the DON showed that additional PRN morphine could have been administered before the transfer time, and the record did not show any documentation that PRN morphine was offered and refused after the 7:01 AM dose.

The hospice Director of Clinical Services reported being told by facility staff that the resident had “maxed out” on scheduled and PRN pain medications and was being sent to the ER, but hospice determined the resident had not actually reached the maximum allowable pain medication. Hospice stated they could have assessed the resident and adjusted or increased pain medications, and offered to involve the hospice medical director and send a nurse, but the facility declined and proceeded with the ER transfer. The hospital case manager reported being informed that the resident was being sent back due to pain control and behavior concerns and that hospice had offered solutions which the facility declined. The RN caring for the resident stated the resident complained of pain everywhere at a level 10 out of 10, requested IV pain medication and higher doses of opioids than the facility could provide, and that scheduled and PRN morphine were given close together. The RN documented the PRN morphine as effective despite the resident’s continued aggressive behavior and reported offering additional PRN morphine later, but this offer and any refusal were not documented in the medical record. Hospice later reported that the resident’s hospitalization would not have been necessary had hospice been involved in managing the resident’s pain prior to transfer.