F0757

D

Failure to Document Pain Indicators for PRN Opioid Use

Nebraska City, Nebraska Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency related to unnecessary drugs when staff failed to document signs and symptoms of pain to justify the continued PRN use of opioid pain medication for one resident. Facility policy on unnecessary drugs required the attending physician to lead medication management and for each resident’s drug regimen to be reviewed on an ongoing basis, including indications, clinical need, and adequate monitoring for efficacy and adverse consequences. The resident, who had dementia, metabolic encephalopathy, schizoaffective disorder, and major depressive disorder, was admitted to hospice and had active orders for morphine solution 10 mg by mouth/sublingually every 1–2 hours PRN for pain or shortness of breath, along with an order to monitor pain every shift. The comprehensive care plan included an intervention to administer all medications as ordered.

Record review of the resident’s MAR showed morphine was administered multiple times with a documented pain rating of zero, despite the order requiring a pain evaluation for administration. On several occasions, progress notes documented behaviors such as restlessness, agitation, pacing, pushing chairs, sitting on another resident’s bed, refusing cues, being “everywhere,” hitting tables with a walker, and attempting to hit staff, but did not document any indicators of pain or shortness of breath. Additional administrations of morphine were recorded with no accompanying documentation of pain or shortness of breath, including doses given late at night and one dose given specifically for restlessness without pain indicators. The Interim DON confirmed that the MAR reflected a pain rating of zero at the time of morphine administration and that there were no documented indicators of pain or shortness of breath in the progress notes.