F0697

D

Failure to Maintain Scheduled Opioid Therapy and Comprehensive Pain Assessment

Red Wing, Minnesota Survey Completed on 03-02-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that a resident’s scheduled opioid pain medication was re-ordered, available, and administered as ordered, and to provide comprehensive pain assessment and monitoring when doses were missed. The resident had chronic pain syndrome, an above-the-knee amputation of the left leg, post‑traumatic osteoarthritis with contracture of the left hand from shrapnel injury, and PTSD. His MDS showed intact cognition, dependence on staff for transfers and toileting, use of a motorized scooter, and a scheduled pain regimen without PRN or non‑pharmacological pain interventions. The CAA documented frequent moderate pain over five days and directed staff to assess pain each shift, notify the provider of unrelieved pain, and use pharmacologic and non‑pharmacologic interventions. However, the care plan problem statement for pain was left blank, lacked a documented baseline pain level, and did not provide clear guidance for managing chronic pain, scheduled opioid administration, or monitoring when medications were unavailable, despite an intervention requiring a pain scale each shift.

The resident had physician orders for morphine IR 15 mg four times daily for chronic pain and morphine IR 7.5 mg twice daily PRN. The MAR showed that on one day the 4:00 p.m. and 8:00 p.m. scheduled 15 mg doses were not administered because the medication was not available, and a 7.5 mg PRN dose was given at 5:03 p.m. as a substitute. The following morning, the 6:30 a.m. scheduled dose was not administered, and the 11:30 a.m. dose was given late at 1:36 p.m., resulting in four missed scheduled doses and a prolonged gap in full opioid coverage. Progress notes documented repeated contacts with the on‑call provider and pharmacy about the morphine prescription and that the medication was not available. The NP reported having sent a prescription to the pharmacy but did not fax it to the facility that evening and did not provide alternate pain management orders or instructions to monitor for increased pain or withdrawal. A triage RN later reported sending a renewed order to the pharmacy and contacting an on‑call PA. The vitals and intake records for the two days of missed doses showed no documented food intake, with improved intake afterward, and resident and family interviews described decreased appetite during the medication gap.

During this period, the record lacked comprehensive pain assessments that included pain characteristics, documentation of non‑pharmacological interventions attempted or offered, increased monitoring for escalating pain or opioid withdrawal symptoms, or any offer or suggestion of emergency transfer for pain management. The resident reported that when he receives all scheduled morphine doses his baseline pain is 5/10, but during the gap he experienced pain at 10/10, could not get out of bed, had decreased appetite, and increased anxiety with difficulty swallowing. He stated he tends to shut down and not ask for medication when in severe pain and that staff only asked for a numerical pain rating without exploring specifics. His spouse described him as stoic, noted that he was sweating, quiet, confused, and unable to operate the TV remote, and confirmed that he did not call her as he usually did. Multiple nurses described him as stoic and requiring prodding to report pain; one nurse identified in advance that the morphine supply would be insufficient but did not contact the provider due to time constraints, and subsequent nurses confirmed the missed doses and significant pain. The DON acknowledged unawareness of the missed doses, agreed this represented a significant medication error with no provider notification, no monitoring for withdrawal, and no alternative pain management, and confirmed that the facility’s pain management policy did not specify when to complete comprehensive pain assessments, how to document baseline pain, or what steps to follow when scheduled pain medications are missed or unavailable. The pharmacist and medical director characterized the situation as emergent, explained the pharmacology of IR morphine, and stated that even one missed dose should trigger assessment and monitoring for escalating pain and acute opioid withdrawal, underscoring that the clinical team was responsible for ensuring communication, medication availability, and monitoring when a scheduled opioid dose was missed.

The facility’s written pain management policy required evaluation, documentation, and reassessment of pain at regular intervals, with each new report of pain, and after interventions, using an interdisciplinary approach and involving the resident and responsible party. However, the policy did not specify when or where a comprehensive pain assessment must be completed, did not provide guidance for documenting baseline pain, and did not outline steps to follow when scheduled pain medications are missed or unavailable. This lack of detailed procedural guidance, combined with staff failures to timely re‑order morphine, ensure its availability, notify providers of missed doses, and conduct comprehensive assessments and monitoring during the medication gap, led to the resident experiencing unmanaged severe pain, decreased appetite, sweating, confusion, and anxiety during the period when his scheduled opioid therapy was interrupted.