Failure to Maintain Scheduled Opioid Therapy and Comprehensive Pain Assessment
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.
Penalty
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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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