F0697

D

Failure to Provide Timely Pain Medication to Resident With Metastatic Cancer

Roanoke Rapids, North Carolina Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide timely, ordered pain management to a cognitively intact resident with stage IV basal cell carcinoma metastatic to lung and bone, an open malignant wound to the posterior left shoulder, neuropathy, and a history of cervical and thoracic spine surgery. The resident’s admission MDS documented frequent moderate pain interfering with daily activities, with reported pain up to 7/10, and the care plan directed staff to encourage the resident to request PRN pain medication and to offer it as ordered. Physician orders included hydrocodone 5-325 mg every four hours PRN, oxycodone 10 mg every six hours PRN, and gabapentin 800 mg three times daily. The resident’s family member reported that the resident had told him it often took a couple of hours after calling before staff administered pain medication, describing this as a general problem rather than a single incident.

On the evening in question, assignment sheets showed that one nurse was assigned to the resident beginning at 7:00 PM. The MAR for that date showed the evening gabapentin dose was documented with another nurse’s initials, with no time of administration, and the first oxycodone dose on that shift was not given until 1:48 AM the following day, with no hydrocodone documented for that shift. A nurse aide who cared for the resident that evening reported that during initial rounds between 7:00 PM and 7:30 PM, the resident requested pain medication, and she relayed this to the assigned nurse, who said she would get to it. Around 8:30 PM, the resident again reported he still had not received pain medication, and the aide stated she could not locate the assigned nurse despite repeatedly looking for her and observing that the nurse’s medication cart remained in the same place. The aide reported the resident repeatedly called out that he was in pain and that he did not go to sleep because he was hurting.

Another nurse, assigned to a different unit, reported being alerted by staff that the assigned nurse was asleep in her car while residents on that unit, including this resident, needed medications. She stated she could not access the resident’s medications because the assigned nurse had the keys to the medication cart. She contacted the on-call nurse and the DON for assistance and was instructed multiple times to try to awaken the assigned nurse in her car. She and other staff attempted to wake the assigned nurse, who briefly cracked the car door but did not return to the building and went back to sleep. The DON reported receiving calls about the situation later that night, directing staff to awaken the assigned nurse and instructing her to return inside, and then ultimately coming to the facility after midnight, having the assigned nurse reconcile controlled substances, and sending her home. The assisting nurse stated that by the time the DON arrived, the resident still had not received pain medication, and that she was only able to administer oxycodone around 2:00 AM, at which time the resident had tears in his eyes and rated his pain as 20/10. The assigned nurse later stated she had not been feeling well, had gone to her car for a break, and was not aware the resident was in pain or that he had not received pain medication.