Failure to Provide Effective Post‑Operative Pain Management for a Surgical Resident
Summary
The deficiency involves the facility’s failure to provide effective pain management, including administration of ordered analgesics and related medications, for a post‑operative resident with severe spinal surgery pain. The resident had undergone complex lumbar fusion surgery with hardware placement and was admitted with orders from the neurosurgeon for a multimodal pain regimen including oxycodone (5 mg for moderate pain and 10 mg for severe pain every 4 hours PRN), methocarbamol, Tylenol, a Lidoderm patch, and later Lyrica. The MDS documented almost constant pain, worst pain at 8/10 over the prior five days, frequent impact on sleep, and occasional impact on daily function. The resident’s care plan directed staff to administer pain medications per physician orders, evaluate pain and efficacy, monitor aggravating factors, and notify the MD if pain relief was inadequate or if interventions were unsuccessful. Despite these orders and care plan directives, facility staff and the NP altered and restricted the resident’s pain regimen without coordinating with the neurosurgeon and did not consistently administer pain medications as ordered. The NP discontinued the oxycodone 10 mg order and substituted tramadol 50 mg every 6 hours PRN, then intermittently re‑ordered and discontinued oxycodone 10 mg, ultimately reducing the resident to oxycodone 5 mg every 4 hours PRN plus tramadol. The neurosurgeon’s office documented that the resident reported difficulty obtaining pain medications as ordered and that staff at the facility did not want to administer them; the neurosurgeon’s office instructed the facility to “give meds as ordered” and noted the resident’s severe, expected post‑surgical pain. The facility did not contact the neurosurgeon’s office about reducing the pain medication, even though that office was the physician of record for pain management. Nursing staff actions further contributed to inadequate pain control. One RN refused to give pain medication even a few minutes early, including before a scheduled neurosurgical follow‑up, resulting in the resident traveling and waiting for transport without analgesia despite reporting significant pain. A night‑shift LPN repeatedly delayed or withheld ordered narcotic analgesics, told the resident it was “too soon” or that he could not be in that much pain, and did not promptly notify a provider when the resident reported severe, unrelieved pain at 10/10 and had low blood pressure. On the night before the resident called 911, the LPN acknowledged the resident’s reports of severe pain, low BP readings, and his requests to go to the hospital, but only administered tramadol once at 3:15 a.m. and left at least one voicemail without a message before finally speaking with the on‑call provider after the resident had already called 911. The resident, family member, neurosurgeon’s office nurse, and another night‑shift RN and CNA all described frequent severe pain, difficulty obtaining ordered pain medications, and the resident being awake much of the night due to pain, culminating in the resident calling 911 for transfer to the hospital for pain management. The facility’s own pain management policy required staff to advocate for pain management, avoid labeling and judging residents, treat pain early, and report pain scores of 5 or greater twice in 7 days or any single episode of 10/10 to a medical practitioner for possible treatment adjustment and IDT review. The resident’s MAR showed frequent pain scores of 7–10/10 and around‑the‑clock use of PRN opioids, yet staff did not consistently escalate concerns or adjust treatment in collaboration with the neurosurgeon. The DON later acknowledged that the night‑shift LPN believed the resident was “drug‑seeking” and therefore did not feel obligated to contact the MD about increased pain, and that it was unacceptable not to notify the physician when pain increased or when analgesics were withheld due to low BP. The NP also stated that staff should report increased or unrelieved pain and notify the provider when medications are withheld for altered vital signs unless parameters are specified. These documented inactions and deviations from orders and policy resulted in the resident experiencing ongoing severe pain, sleep disturbance, and ultimately calling 911 to obtain hospital‑based pain control. The resident’s experience was corroborated by multiple interviews. The resident reported having a very difficult time getting pain medication as ordered, described severe post‑surgical pain that was only partially relieved by oxycodone 10 mg, and recounted that a night‑shift nurse ignored or minimized his requests, told him it was too soon for medication, and delayed contacting the physician when his pain remained at 10/10 for several hours. The resident’s family member stated staff were not good about giving pain medication as prescribed, that the resident had to constantly ask and wait, and that this worsened his pain and anxiety. A CNA described the resident being up most of the night due to pain and repeatedly asking to go to the hospital. Another night‑shift RN confirmed the resident’s frequent pain scores of 7–10/10, non‑verbal signs of pain, and need for oxycodone 10 mg about every 4 hours, and stated he did not believe the resident was drug‑seeking. EMS and ED records documented the resident’s 10/10 back pain on arrival, the need for multiple IV and oral medications including strong opioids and non‑opioid agents, and that the resident had called 911 from the facility for pain management. The facility’s Administrator was initially unsure whether the resident’s pain had been addressed by the IDT as required by policy and later stated that the IDT recommended assessment by their provider, without providing a date. The facility’s pain policy also required reporting of significant pain episodes and IDT review, but the record did not show timely, effective IDT intervention in response to the resident’s persistent high pain scores and repeated complaints. Overall, the documented actions and inactions by the NP and nursing staff, including altering the neurosurgeon’s pain regimen without consultation, rigid timing and withholding of ordered analgesics, failure to promptly notify providers of severe, unrelieved pain and low BP, and failure to follow the facility’s own pain management policy, led to the resident experiencing inadequately managed post‑operative pain, sleep disturbance, and the need to seek emergency care by calling 911.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with idiopathic aseptic necrosis of the right femur and ongoing hip pain had a PRN oxycodone order every 4 hours, but the medication was delayed after the resident and CNAs reported the need for pain relief. The LPN stated the dose was not yet due and later said the resident was asleep, while the DNS said the delay occurred after an early morning fire drill and resulted in the resident going 7 hours without PRN pain medication when it could have been given every 4 hours.
Pain medication was not available for two residents, one resident’s morphine order was not received by the pharmacy and the first dose was delayed for more than a day after admission, and another resident missed several days of Lidocaine patch therapy because the facility ran out of stock. The second resident also had a physician order without a dose listed and a pain CAA that was not carried into the care plan. The resident reported increased back pain and poor sleep without the patch, while family and staff confirmed ongoing pain and missed doses.
The facility failed to manage pain according to physician orders for several residents. One resident received acetaminophen for pain rated above the ordered mild-pain range and without documented nonpharmacological interventions, two residents received hydrocodone-acetaminophen when their pain scores did not match the ordered parameters, and another resident lacked an order covering moderate pain levels. Staff interviews and MAR review confirmed the medications were not always administered as ordered.
A resident with moderate cognitive impairment, dysphasia, chronic pain, and almost constant pain did not receive scheduled pain meds on time. The resident was in severe pain during the morning, declined PT because pain meds had not yet been given, and later yelled for help while the RN struggled to administer oral meds and applied lidocaine patches even later. The RN said he was delayed by wound care for two other residents, and the PT and RN noted timely pain control may have improved participation in therapy and reduced pain during care.
A resident with cancer, a lower back condition, a right leg fracture, and palliative care needs reported severe leg pain, but scheduled methadone and morphine were not given until about 4 hours after the ordered 8:00 a.m. time. An LN said the delay happened because another LN called off and the workload increased. The DON stated meds should be given within 1 hour of the scheduled time.
A facility failed to consistently follow PRN pain medication orders for three residents with significant pain-related diagnoses, including fractures, cancer, and osteoarthritis. MAR review showed pain meds were given at pain levels that did not match the ordered severity ranges, including opioids administered when pain was documented as 0 or mild and, in one case, not given when severe pain was documented. An LPN confirmed the orders were not consistently followed and that there was no documentation explaining why.
Delayed PRN Pain Medication Administration
Penalty
Summary
The facility failed to ensure appropriate pain management for Resident 23, who was admitted with diagnoses including idiopathic aseptic necrosis of the right femur, a condition associated with pain, stiffness, and limited mobility. A physician order dated 6/19/26 directed PRN oxycodone every four hours for this condition. On 6/24/26, the resident requested pain medication after having last received oxycodone at 10:38 PM on 6/23/26, making the medication available again at 2:38 AM. According to the incident report, CNAs notified Staff 14 that the resident needed pain medication, but Staff 14 stated the medication was not yet due. The resident later went to the medication cart and again requested pain medication, and the medication was not given until about 4:45 AM, with the incident report noting it was administered at 5:02 AM. Camera review showed a CNA left the resident’s room at about 2:30 AM and went to Staff 14, and the resident was seen at the nurses’ station at about 4:30 AM speaking with Staff 14 before returning to the room. Resident 23 stated the pain medication should have been given around 2:30 AM and that the right hip hurt at all times, with pain rated 7 or 8 out of 10. Staff 14 stated the resident requested the medication too soon and that the resident was asleep when she went into the room around 4:00 AM. Staff 2, the DNS, stated the late PRN medication concern was investigated and determined that Staff 14 waited until after an early morning fire drill to provide the medication, resulting in the resident not receiving the PRN pain medication for seven hours when it could have been given every four hours. Staff 8 stated she notified the nurse two to three times about the resident’s need for pain medication.
Pain Medication Not Available and Pain Care Not Addressed
Penalty
Summary
The facility failed to ensure pain medication was available for administration for two residents, failed to clarify a physician order for a pain medication dose for one resident, and failed to initiate a care plan for pain that had been triggered on the CAA for one resident. These failures affected two of the three residents reviewed for pain and included one resident receiving hospice comfort-focused care and another resident with chronic back pain and moderate cognitive impairment. One resident was admitted to the facility by ambulance and had a hospice diagnosis of end stage heart failure. The resident had a physician order for Morphine Sulfate concentrate, 10 mg sublingually every hour as needed for pain and/or air hunger, but the July MAR documented no morphine administration on the day of admission. The MAR also included pain monitoring every shift, but no pain monitoring was documented that day. The first documented morphine dose was given about 26 hours after admission. A nursing note documented that the resident’s family requested as-needed pain medication and staff were unable to locate it, and follow-up with hospice and the pharmacy showed the prescriptions had not been received and were pending clarification regarding which pharmacy was to receive the orders. Pharmacy staff later stated the order received did not include morphine. A CNA also observed the resident appearing uncomfortable during repositioning, with grunting on movement. The second resident had diagnoses including lumbar intervertebral disc degeneration with discogenic back pain, functional quadriplegia, muscle wasting and atrophy, and abnormal posture. The resident’s MDS documented moderate cognitive impairment and occasional moderate-severe pain, and the CAA identified pain as a problem to be carried over to the care plan. However, the current care plan did not include a pain category or interventions to direct staff on pain relief. The physician order for Lidocaine External Patch listed application to the affected area once daily for mild pain, but no dose was identified. The MAR and nursing notes showed the Lidocaine patch was not administered for several consecutive days because the facility was out of stock, with one date signed as given in error. During interview, the resident stated the patch had not been applied for several days, that the resident had never refused it, and that without the patch the back pain increased to 7 to 8 out of 10 and interfered with sleep. The resident reported that Tylenol lowered the pain somewhat, but the patch maintained pain at about 2 out of 10. The resident’s family member stated the resident had pain all the time and that the Lidocaine patches helped take the edge off.
Pain medications given outside ordered parameters and missing pain-level coverage
Penalty
Summary
The facility failed to provide necessary pain management care and services for four residents. The report identified that pain medications were administered outside of ordered pain parameters, nonpharmacological interventions were not provided before medication administration, and one resident did not have an order covering all pain levels. The facility’s pain management policy stated that residents receiving pain interventions would be monitored for effectiveness and side effects, and that nonpharmacological interventions, effectiveness of PRN medications, and physician notification would be documented. For one resident, acetaminophen 325 mg was given after the resident reported generalized pain at a level of 6 on a 0 to 10 scale, even though the order was for mild pain only, defined as 1 to 4. The nurse did not offer or provide any nonpharmacological interventions before giving the medication, and the medication was administered outside the ordered parameters without notifying the physician. The resident’s record showed capacity to make his own medical decisions. For another resident, hydrocodone-acetaminophen 5-325 mg was administered multiple times when the documented pain level was outside the ordered range. The resident had an earlier order for moderate pain at 5 to 7, later changed to severe pain at 8 to 10, yet the MAR showed doses given for pain levels of 8 when the moderate-pain order was active and for pain levels of 7 after the severe-pain order was in place. Staff interviews confirmed the medication was to be given only within the physician’s ordered pain parameters. A third resident received hydrocodone-acetaminophen 10-325 mg for a pain level of 4 even though the order was for pain levels of 5 to 10. Another resident had orders for acetaminophen for mild pain and hydrocodone-acetaminophen for severe pain, but the record did not show any physician order for pain levels of 5 to 7. The resident’s MAR showed repeated use of hydrocodone-acetaminophen for severe pain, and no PRN acetaminophen was documented as given. The DON acknowledged that there should have been an order covering pain levels of 5 to 7.
Delayed Pain Medication Administration
Penalty
Summary
The facility failed to ensure pain medication was administered timely for a resident with moderate cognitive impairment, bilateral lower extremity impairment, muscle weakness, a history of TIA and cerebral infarction, dysphasia, chronic pain, and almost constant pain. The resident’s MDS indicated she received scheduled and PRN pain medication, and her care plan directed staff to administer analgesics as ordered and give pain medications per schedule to maintain therapeutic levels. Her pain interview also identified a condition that usually caused pain and that pain was typically worse in the morning. On the morning of the observation, the resident had not yet received her scheduled pain medications, including acetaminophen ER, gabapentin, hydromorphone, and lidocaine patches. During PT arrival, she declined therapy and stated she was in too much pain and had not received pain medication yet. When the RN later came to assess and medicate her, the resident was in significant pain, yelling for help and reporting pain in her stomach, arms, and legs. The RN had difficulty administering the oral medications because of swallowing difficulty and left to get applesauce, delaying completion of the scheduled pain medications until later in the morning. During repositioning and incontinent care, the resident verbalized increased pain with each turn, and the lidocaine patches were applied even later. The RN stated he was tied up with wound care on two other residents and confirmed the pain medications were given very late; the PT and RN both stated timely pain medication may have allowed the resident to participate in therapy and experience less pain during morning care. The DON stated the expectation was that residents receive pain medications on time, within one hour before or after the scheduled time.
Delayed Administration of Scheduled Pain Medications
Penalty
Summary
Safe, appropriate pain management was not provided for one sampled resident when scheduled pain medications were not administered as ordered. Resident 13 had diagnoses including secondary malignant neoplasm of the brain, spondylosis of the lumbosacral region, a right tibia and fibula fracture, and was receiving palliative care services. The resident’s MDS showed a BIMS score of 10/15, indicating moderate cognitive impairment. During a concurrent observation and interview, the resident was awake and reported leg pain rated 15/10, and the resident told CNA 1 that she was experiencing pain. The resident’s OSR and medication administration history showed methadone 10 mg/mL, 0.5 mL by mouth every eight hours for pain management, scheduled for 8:00 a.m., and morphine sulfate oral solution 20 mg/mL, 1 mL by mouth every eight hours for pain or shortness of breath, also scheduled for 8:00 a.m. Both medications were not administered until about 12:21 p.m. and 12:22 p.m. LN 1 stated the medications were given around noon and acknowledged they were scheduled for 8:00 a.m., explaining the delay was due to another LN calling off and an increased workload. LN 1’s note stated the resident received routine pain medications late and did not appear to be in pain at that time. The DON stated the expectation was for nurses to address and manage residents’ pain and that medications should be administered within one hour before or after the scheduled time.
Inconsistent PRN pain medication administration
Penalty
Summary
The facility failed to ensure safe, appropriate pain management for three residents whose PRN pain medication orders were not consistently followed. Resident 1 was admitted with diagnoses including vertebral fracture, lung cancer, and diabetes, had moderately impaired cognition, and was assessed as receiving PRN pain medications. Her care plan addressed chronic pain related to a general body recent injury, and her physician ordered acetaminophen 500 mg every 4 hours as needed for pain rated 1-4, hydrocodone-acetaminophen 1 tablet every 4 hours as needed for moderate pain rated 4-7, and hydrocodone-acetaminophen 2 tablets every 4 hours as needed for severe pain rated 8-10. Resident 1’s MAR showed acetaminophen was given when pain was documented at 8, 5, 7, and 5, and hydrocodone-acetaminophen 1 tablet was given when pain was documented at 3. The MAR also showed hydrocodone-acetaminophen 2 tablets was not given when pain was documented at 8. During interview and record review, LN 2 confirmed the pain medication orders were not consistently followed and that there was no documentation explaining why the orders were not followed. Resident 3 was admitted with diagnoses including right hip fracture, bone cancer of the lower right leg, cancer of connective and soft tissue, and right leg pain, and had moderately impaired cognition. Her care plan addressed acute pain due to cancer diagnosis, and her physician ordered hydromorphone 4 mg 1 tablet every 4 hours as needed for moderate pain rated 4-7 and 2 tablets every 4 hours as needed for severe pain rated 7-10. The MAR showed 1 tablet was given when pain was documented at 9, 9, 9, and 8, and 2 tablets were given when pain was documented at 0, 3, 3, 6, 6, 6, 6, 2, 2, 6, and 6. LN 2 confirmed the orders were not consistently followed and that there was no documentation explaining why. Resident 4 was admitted with diagnoses including osteoarthritis, difficulty walking, and depressive episodes, had intact cognition, and was receiving scheduled pain medications, PRN pain medications, and non-medication interventions for pain. Her care plan addressed pain or discomfort related to bilateral osteoarthritis, left hand discomfort/tingling, and right foot pain. Her physician ordered oxycodone 5 mg 1 tablet every 4 hours as needed for moderate pain and 2 tablets every 4 hours as needed for severe pain. The MAR showed 1 tablet was given when pain was documented at 0, and 2 tablets were given numerous times when pain was documented at 0, 1, 2, 3, 4, 5, and 6. LN 2 confirmed the pain medication orders were not consistently followed, and there was no documentation explaining why the orders were not followed. The DON stated nurses should administer PRN pain medications based on assessed pain severity and that the assessed 0 pain levels were probably follow-up assessments after pain medication.
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