F0697

G

Failure to Assess and Manage Pain for Newly Admitted Nonverbal Resident

Barry, Illinois Survey Completed on 01-16-2026

Penalty

9 days payment denial

Summary

The deficiency involves the facility’s failure to assess and manage pain for a newly admitted, largely nonverbal resident with known pain-related diagnoses. The resident was admitted from another nursing home with documented diagnoses including chronic pain and Lupus, and with PRN pain medication orders at the prior facility. On admission, the facility’s baseline care plan was handwritten, unsigned, and did not document the resident’s yelling/screaming, cognition, or communication status. The face sheet omitted the chronic pain diagnosis. Shortly after arrival, an LPN documented that the resident was yelling out, very restless, and grabbing at the groin area, but did not complete or document a pain assessment. The admitting nurse did not obtain nurse-to-nurse report from the sending facility, despite multiple attempts, and did not escalate the lack of report to the DON at the time of admission.

From the time of admission through the following day, the resident was repeatedly observed and reported by staff and surveyors to be yelling or screaming continuously without a timely, comprehensive pain assessment or appropriate use of PRN pain medication. On the evening of admission, the night-shift LPN heard the resident yelling upon arrival, was told by the day-shift LPN that the resident had been yelling since admission and that the admission assessment and baseline care plan were incomplete, but did not complete the admission nursing assessment or a nonverbal pain assessment. Instead of reviewing the prior records or diagnoses, the night-shift LPN assumed the behavior was anxiety-related and administered PRN Ativan, documenting it as effective without documenting any assessment. CNAs reported that the resident yelled most of the night, sleeping only about an hour, and that they were told by nursing staff that “that’s just what she does,” despite the resident being new and nonverbal.

The following morning, surveyors directly observed the resident yelling continuously in bed and later during transfer and at lunch. The MAR showed no PRN Tylenol given on the day of admission and only one PRN Tylenol dose given the next morning, which was documented as ineffective. There was no documented admission pain assessment or pain assessment every shift until a pain assessment order was entered the day after admission. A later pain evaluation documented that the resident was rarely or never understood, exhibited nonverbal sounds such as crying or moaning, and had pain indicators 1–2 days, with no scheduled pain regimen in place and only PRN Tylenol and positioning used. The DON and the nurse practitioner both stated that they expected an admission pain assessment within hours of admission, review of prior records for pain diagnoses, administration and reassessment of PRN pain medication, and timely notification of the provider when pain was not controlled. The facility’s own policies required pain assessment at admission and ongoing, and required the admitting nurse to conduct a pain assessment as part of the admission assessment, but these processes were not carried out for this resident, resulting in prolonged yelling/screaming without appropriate pain assessment or management.

The facility also failed to obtain and document nurse-to-nurse report from the sending facility at or before admission, despite multiple attempts, and staff did not notify the DON when they were unable to obtain this baseline information. As a result, staff did not know whether the resident’s yelling and restlessness represented her baseline or a change in condition. The DON stated that it is standard practice and expectation to obtain report from the prior facility to understand the resident’s baseline and that staff should have reported the inability to obtain this information. The combination of incomplete admission assessment, lack of timely pain assessment, failure to administer PRN pain medication initially, reliance on an anxiolytic instead of analgesia without adequate assessment, and failure to secure prior-facility report led to the resident yelling/screaming for many hours without appropriate pain management, as documented by staff interviews, progress notes, MAR review, and surveyor observations.