Failure to Ensure Continuous and Effective Pain Management for Hospice Residents
Summary
The deficiency involves the facility’s failure to provide effective pain management for three residents receiving pain control, including one hospice resident at end of life. One resident with multiple myeloma, pulmonary embolism, chronic pain, spinal stenosis, osteoporosis with pathological fractures, fibromyalgia, and other comorbidities was on hospice care with orders for a Fentanyl patch, scheduled oral Dilaudid every two hours, and PRN Hydrocodone for breakthrough pain. Her care plan called for evaluation of pain, monitoring for non-verbal indicators, and assessing the effectiveness of pain interventions every shift. Despite this, the facility allowed her oral Dilaudid supply to be depleted and did not ensure timely replacement, resulting in a period of approximately six hours without the ordered narcotic while she was actively dying. Family members reported that on the day in question the resident was in severe, uncontrolled pain, thrashing and crawling in bed, attempting to get out of bed, and requiring family to hold her to prevent falls. Multiple family members stated that the facility could not get her Dilaudid all day, that they repeatedly called hospice and even a hospital seeking help, and that the resident suffered intensely until medication finally arrived later in the afternoon. The hospice RN had identified the day before that the Dilaudid supply would not last, sent refill orders to the facility’s pharmacy before noon, and instructed facility staff to notify hospice if the medication was not delivered so alternate arrangements could be made. The hospice RN reported she never received such a call and only learned the medication was depleted after the last partial dose was given around 10:00 a.m. Facility nurses confirmed that the last dose from the bottle was given that morning, that no additional Dilaudid was available in the building, and that they relied on hospice to locate an open pharmacy and bring replacement medication, which did not arrive until mid- to late afternoon. During the period without Dilaudid, staff documented that the resident’s scheduled doses at noon and 2:00 p.m. were not given and coded as “other/see progress notes,” while the resident exhibited restlessness, grimacing, and agitation as described by CNAs and family. An agency LPN caring for the resident stated she considered sending the resident to the emergency room for pain relief but did not do so, and another nurse reported that the facility’s pharmacy did not make Sunday deliveries. The primary physician/medical director stated he was not notified that the resident was out of Dilaudid or that her pain had increased. The facility’s own pain management policy required recognition of behavioral signs of pain and review of the MAR to determine the effectiveness and frequency of pain medication use, but the resident’s MDS documented no receipt of scheduled or PRN pain medications or non-medication interventions despite concurrent documentation that she was receiving an opioid. Two additional hospice residents with pain needs also did not receive adequate pain assessment and management. One resident with multiple sclerosis, contractures, and other serious conditions was on a scheduled Norco regimen three times daily and had PRN Dilaudid ordered for moderate to severe pain and dyspnea. He reported that he was always in pain, that staff did not routinely ask him about pain, and that he had to request medication himself, sometimes forgetting until his pain became severe. His MAR showed all scheduled Norco doses documented with a pain level of 0 over multiple days and no use of PRN Dilaudid during the review period, while a hospice CNA stated she always asked him about pain and that he consistently reported being in pain. Another hospice resident with Parkinson’s disease, severe dementia, heart failure, and other diagnoses had orders for scheduled Oxycodone four times daily and PRN Hydromorphone every four hours. His care plan required monitoring and recording pain characteristics every shift and observing for non-verbal signs of pain such as changes in breathing, facial expressions, and vocalizations. However, his MAR documented pain scores of 0 on all shifts over several weeks and no administration of PRN Hydromorphone. A hospice CNA reported that this resident complained of pain at times and that she had to notify the nurses. During observation, the resident was seen flinching in his legs, grimacing, gritting his teeth, and trying to adjust his feet, yet he was unable to answer questions, indicating reliance on staff to recognize and respond to non-verbal pain behaviors that were not reflected in the recorded pain assessments.
Removal Plan
- The DON, ADON, and floor nurses began assessing residents for pain using a standardized scale; residents with pain received immediate intervention; physicians were notified and new orders obtained as needed.
- The DON began re-educating licensed staff; education included medication inventory and physician notification.
- Licensed staff were educated to notify the physician if any medication is not available.
- Licensed staff were educated to notify the DON immediately if medication is not available or if there will be a delay in receiving ordered/reordered medications immediately upon discovery of a medication shortage.
- All notifications and order changes are to be documented in real time.
- The DON and ADON will complete medication audits to ensure residents always have an adequate amount of pain medications available.
- If less than four days of medications are noted, an order/reorder will be submitted to the physician; this audit will include hospice residents.
- Licensed staff unable to attend the education were educated via phone with the DON and ADON as a witness.
- A message was sent to all licensed staff via Mediprocity with the education.
- The DON/designee initiated real-time audits.
- The DON and ADON completed a 100% house-wide audit comparing pharmacy-dispensed medication orders for pain management to on-hand inventory; reorders were processed and delivered; orders were clarified/updated as needed; care plans were revised as needed.
- The DON/designee will complete biweekly audits for 4 weeks.
- The Administrator and DON will submit the plan to QA for monthly review.
- The QAPI committee will review and offer recommendations as needed until compliance is met.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to follow pain management orders and policy for two residents. One resident with hydrocephalus, neuropathy, and chronic back pain received PRN oxycodone when documented pain scores were below the ordered 7-10 range. Another resident, who was cognitively intact after knee replacement surgery, received PRN oxycodone-acetaminophen multiple times without a documented pain score and without documentation of attempted non-pharmacological interventions before administration. The DON confirmed the findings.
A resident with chronic pain, dementia, and other diagnoses repeatedly requested PRN oxycodone-acetaminophen after being assisted to bed, while multiple CNAs alerted an RN that the resident was also making threatening comments. The RN addressed the behavior but did not complete a documented pain assessment, contact the provider, or give the opioid until hours later, after the resident reported being in agony and said the medication had been withheld because of her statements.
Failure to Document Non-Pharmacological Pain Interventions: Staff failed to document non-pharmacological pain measures before giving PRN analgesics to multiple residents. One resident received repeated Tylenol and oxycodone doses, another received multiple PRN oxycodone doses with a care plan calling for relaxation, guided imagery, music, distraction, and massage, and a third resident had a PRN Tylenol order and pain care plan but no documented evidence that non-drug interventions were attempted or effective.
Failure to Monitor and Treat Severe Pain After Ankle Injury: A resident with acute respiratory failure and COPD sustained an ankle injury while transferring to a wheelchair and reported severe pain rated 8/10 to 10/10. Staff applied ice, elevated the foot, and gave PRN acetaminophen, but the MAR documented it as ineffective and the resident continued to report severe pain for hours. An X-ray later showed an acute fracture, and the resident was not transferred to the ED until late that night after the delayed imaging result was obtained.
A resident with severe dementia, a BIMS of 3, and diagnoses including traumatic subarachnoid hemorrhage, weakness, and difficulty walking was supposed to have pain assessed using nonverbal indicators and PAINAD. Instead, staff documented some pain assessments with a numerical pain scale even though the resident could not verbalize pain levels and was unable to answer questions during observation. The NP, DON, ADM, and nursing staff stated PAINAD was the expected tool for this resident, and the facility’s pain policy required a pain tool appropriate to cognitive status.
A resident with severe cognitive impairment, CVA, Alzheimer's disease, seizure disorder, and osteoporosis had pain that was not comprehensively assessed or consistently managed. Staff documented flinching, swelling, and reported pain, but did not record a pain intensity score or location, and PRN Tramadol was not given for one episode of left leg pain despite an existing order. On another occasion, Tramadol was administered for mild pain, but the assessment still did not identify the pain location, and an LPN stated the resident was not in pain without moving or touching the resident during the assessment.
Failure to Follow PRN Opioid Pain Medication Orders and Documentation Requirements
Penalty
Summary
The facility failed to provide pain management in accordance with physician orders and its pain management policy for two residents. The policy required residents to be assessed for pain using an appropriate pain scale, to attempt non-pharmacological interventions before giving PRN pain medication, and to document medication administration and the resident’s response in the eMAR. The policy also directed staff to give the medication that matched the physician-ordered pain intensity when multiple PRN pain medications were available. Resident 30 was admitted with hydrocephalus, neuropathy, and chronic back pain. The physician ordered oxycodone HCl 5 mg every 4 hours as needed for severe breakthrough lower back pain rated 7 through 10. Review of the eMAR showed oxycodone was administered on three occasions when the documented pain ratings were 4, 5, and 6, which were below the ordered range for administration. Resident 47 was admitted after right total knee replacement surgery and had chronic kidney disease. A quarterly MDS dated June 4, 2026, showed the resident was cognitively intact with a BIMS score of 15. The physician ordered oxycodone-acetaminophen 5 mg/325 mg every 4 hours as needed for moderate to severe pain rated 4 through 10, but the eMAR showed multiple administrations without a documented pain rating and without documentation that non-pharmacological interventions were attempted before the medication was given. The DON reviewed the findings and confirmed the facility failed to ensure pain management was provided in accordance with physician orders, facility policy, and accepted standards of practice.
Delayed PRN opioid pain medication after repeated requests
Penalty
Summary
The facility failed to provide safe, appropriate pain management for a resident with chronic pain when a nurse did not timely assess and administer a prescribed PRN opioid after repeated requests from the resident and alerts from multiple CNAs. Resident 33 had diagnoses including muscular dystrophy, major depressive disorder, moderate dementia without behavioral disturbance, and personality disorder, and her care plan identified chronic pain with a goal to remain free from pain or at a level of discomfort acceptable to her. Her physician orders included oxycodone-acetaminophen 7.5-325 mg every 6 hours as needed for moderate pain and acetaminophen 325 mg, 2 tablets every 8 hours as needed for pain. On the night of the incident, Resident 33 was assisted to bed and repeatedly requested her pain medication while also making statements about killing people with guns, a BB gun, a paint gun, and a water gun. Multiple CNAs reported both the resident’s statements and her request for pain medication to RN 1. RN 1 entered the room to address the threatening statements, but the resident became hostile and told the nurse to leave. Documentation showed no pain assessment, no contact with the provider or facility leadership, and no documented response to the resident’s repeated requests for pain medication at that time. Resident 33 did not receive pain medication until approximately 4:09 AM, more than 18 hours after the prior dose and more than 4 hours after the initial request during the night. The resident reported that she had been in agony for hours and that the nurse refused to give her the medication because of the statements she had made. CNA statements and RN 1’s own account confirmed that the resident asked for the medication multiple times before it was finally administered. The DON stated that pain must be treated subjectively based on the resident’s report and that if a nurse had safety concerns about giving a narcotic, the nurse must contact the on-call medical provider or facility clinical leadership for guidance.
Failure to Document Non-Pharmacological Pain Interventions
Penalty
Summary
Facility staff failed to document attempts at non-pharmacological pain interventions before administering pain medications for multiple residents. For Resident #124, the record showed PRN orders for acetaminophen 325 mg, 2 tablets every 4 hours for pain 1-5, and oxycodone 10 mg every 4 hours for pain 6-10. The MAR showed repeated administration of Tylenol and oxycodone throughout June 2026, but review of the TAR and progress notes did not show documentation of non-pharmacological interventions before these medications were given. For Resident #18, the record showed active PRN oxycodone orders for moderate and severe pain, and the MAR showed multiple administrations of both strengths in June 2026. The care plan identified non-pharmacological approaches such as relaxation, guided imagery, music, distraction, and massage before, after, and if possible during painful activities or before pain occurs, but the record did not show documented evidence that these interventions were implemented before opioid administration. For Resident #10, the clinical record showed a PRN Tylenol order and a pain care plan with the same non-pharmacological approaches, but there was no evidence staff documented attempts at these interventions or whether they were successful.
Failure to Monitor and Treat Severe Pain After Ankle Injury
Penalty
Summary
The facility failed to comprehensively monitor and implement appropriate interventions for a resident’s new onset and worsening pain in accordance with physician orders and facility policy. Resident 105 was admitted with acute respiratory failure and COPD, and her admission MDS showed she was cognitively intact with a BIMS score of 15. The facility’s pain policy stated that pain management should be provided consistent with professional standards, the care plan, and resident goals and preferences, and that pain should be reassessed at established intervals with revisions made if pain was not adequately controlled. On June 10, 2026, Resident 105 activated the call bell at about 4:30 AM and was observed halfway off the bed while trying to transfer to a wheelchair. She stated she struck her ankle on the wheelchair while attempting to go to the bathroom, could move the foot and ankle and wiggle her toes, and reported pain rated 10 out of 10. Staff applied ice, elevated the foot, and notified the nursing supervisor. At 5:40 AM, the resident reported continued pain radiating up the leg and requested acetaminophen. The MAR showed acetaminophen 650 mg was given for pain and documented as ineffective at 5:26 AM, and the pain level tab recorded pain ratings of 8 out of 10 at 4:30 AM, 10 out of 10 at 5:26 AM, and 10 out of 10 at 6:50 AM. A late-entry progress note at 9:00 AM documented left ankle pain with bruising, swelling, difficulty walking, and orders for an X-ray, therapy as needed, orthopedic follow-up as needed, acetaminophen, baclofen, and continued monitoring. The X-ray was performed at 4:51 PM and later reported an acute nondisplaced fracture of the left ankle/fibula. The resident remained in pain rated 8 out of 10 when transferred to the emergency department at 11:46 PM, and she stated during interview that she remained in severe pain until hospital transfer. The nursing supervisor stated she contacted the radiology provider around 11:00 PM to obtain the delayed X-ray results, then notified the on-call physician and initiated transfer after the fracture was confirmed. The NHA was unable to provide documented evidence of ongoing pain assessments or additional pain interventions between the injury and the transfer to the emergency department.
Improper Pain Assessment for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure safe, appropriate pain management for one resident who required pain services and had severe cognitive impairment. The resident was admitted with traumatic subarachnoid hemorrhage, difficulty walking, lack of coordination, muscle weakness, and Alzheimer’s disease. Her quarterly MDS reflected a BIMS of 3, and her care plan identified her as at risk for pain and as rarely or never understanding in her ability to express ideas and wants. The order summary directed staff to assess pain every shift using non-verbal/noncognitive signs of pain because her pain intensity score could not be verbalized and she had a cognizant deficit. Review of the pain summary showed that on several dates staff assessed the resident’s pain using a numerical pain scale, while the remainder of the assessments from the same period were completed using PAINAD. During interview, the resident’s RP stated the resident had severe dementia, severe cognitive impairment, and diminished mental capacity, and was unable to verbalize or express pain levels. During observation, the resident was sitting in a wheelchair at the memory care unit nurse’s station and had a dark red laceration on the left side of her forehead with stitches; she was unable to answer questions when the surveyor attempted to interview her. The NP, DON, ADM, and nursing staff all stated they expected PAINAD or another nonverbal pain assessment tool to be used for this resident because she could not reliably report a numerical pain score. The DON and ADM were not aware that staff had used a numerical pain scale instead of PAINAD. The facility’s pain management policy stated that staff would observe for nonverbal indicators of pain and use a pain assessment tool appropriate for the resident’s cognitive status.
Incomplete Pain Assessment and PRN Pain Management
Penalty
Summary
The facility failed to comprehensively and accurately assess and manage pain for one resident with severe cognitive impairment who was dependent on all ADLs and had diagnoses including CVA, Alzheimer's disease, seizure disorder, and osteoporosis. The facility's pain management policy required observation for physiologic and behavioral signs of pain and evaluation of pain intensity, description, pattern, location, and frequency/timing/duration, with documentation of the results of any medication intervention. The facility used the PAINAD tool for residents with advanced dementia, but the pain assessments documented for this resident did not include pain intensity or location. On one occasion, a licensed nurse documented that the resident had left hip pain, flinched when the left knee was touched, and had slight edema to the left knee; the physician was notified and ordered an ace wrap and elevation, but the assessment did not record a pain score. The resident had an existing PRN order for Tramadol 50 mg every six hours as needed for pain, yet the MAR showed no Tramadol was given for the left leg pain that day. On another occasion, Tramadol was administered for a pain level of 3, but the pain assessment did not identify the pain location. During interview, one nurse stated the resident was not in pain and admitted not touching or moving the resident during the assessment, despite the companion reporting pain when the resident was moved and repositioned.
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