F0684

G

Failure to Provide Adequate End-of-Life Pain and Anxiety Management for Hospice Resident

Bellaire, Ohio Survey Completed on 03-17-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate end-of-life care, pain management, and monitoring for a hospice resident admitted for comfort-focused services. The resident had advanced pancreatic cancer with liver metastases, severe pain, depression, insomnia, and total dependence for care. Prior to transfer, the inpatient hospice facility documented severe pain (7/10), facial grimacing, restlessness, agitation, and multiple non-verbal pain indicators, and had the resident on an active regimen of Roxanol, Morphine, MS Contin, Ativan, and other medications for pain and anxiety. Hospice records show that on the morning of transfer, the resident received multiple doses of Roxanol, Morphine, and Ativan for pain, restlessness, and facial grimacing, and that hospice staff faxed all paperwork, including signed scripts for Roxanol and an e-scribed Ativan order, to the receiving facility and verbally informed an LPN that the Roxanol script was signed and should be available from the facility’s pharmacy.

Upon admission to the facility, critical admission processes and assessments were not completed. The nursing admission checklist had blank sections for code status, consents, physician-verified orders, diet, and nursing assessments, and it was not signed by the nurse. Multiple required assessments, including admission, bowel and bladder, Braden, fall, oral, TB, vitals and pain evaluation, AIMS, and elopement, were left blank; only a functional assessment and a pressure ulcer assessment (completed the day after admission) were documented. There was no evidence that an acute plan of care was initiated. Admission orders showed no medication orders, no diet orders, and no urinary catheter orders, despite hospice transfer information listing multiple active pain and anxiety medications and catheter care instructions. A drafted progress note by an LPN stated that consents were signed, history obtained, and medications reviewed with the physician, but also stated “No medications were ordered at this time” while simultaneously referencing “Morphine and Ativan for comfort,” and there was no evidence that an Ativan order was actually entered.

The only documented facility order for symptom control was Morphine 20 mg three times daily, and this order was not implemented in a timely or consistent manner. Pharmacy records show the Morphine order was sent to the pharmacy late in the morning, pulled from the emergency box in the afternoon, but the first documented administration did not occur until 7:30 p.m., several hours after admission and after the resident’s wife reported ringing the call light for pain medication without response. The MAR shows only two doses of Morphine 20 mg given (bedtime on the day of admission and the morning of the next day), both signed by a medication technician who documented a pain score of zero, with no evidence of a comprehensive pain assessment before administration. The Morphine control sheet, however, reflects three doses signed out, including a 1:50 p.m. dose on the second day that was not documented on the MAR. There was no documentation that Ativan was ordered or administered, despite hospice and pharmacy confirmation that Ativan orders were submitted, and despite an LPN telling the hospice nurse that an as-needed Ativan dose had been given.

On the second day, a visiting hospice RN documented that the resident’s wife wanted him returned to inpatient hospice for pain control and that the resident’s pain level was 9/10. The hospice RN recorded that an LPN stated the resident “was fine until his wife got here” and described the wife as unrealistic about his decline. The LPN reported having given Ativan at 10:00 a.m. and that Morphine was due at 2:00 p.m., but there was no corresponding Ativan order, control sheet, or MAR entry. The resident’s wife reported that staff attempted to force feed the resident despite his having had no intake for two days, that call lights for pain medication were unanswered, and that when she requested liquid Morphine and Ativan for his obvious pain and restlessness, staff refused or stated it was not time for his medication and gave multiple excuses for the lack of Ativan. Photos provided by the wife and reviewed by facility leadership showed the resident at the edge of the bed, restless and trying to get up, with facial grimacing consistent with pain. After transfer back to the inpatient hospice facility later that day, hospice records show frequent administration of Morphine, Roxanol, Ativan, and Haldol for pain, anxiety, and restlessness until the resident’s death the following day. Corporate and hospice representatives confirmed that, while multiple pain and anxiety medications were ordered at the time of transfer, the facility only had a Morphine order in place, did not complete admission assessments or pain evaluations, and did not implement or document the full ordered pain and anxiety regimen during the resident’s stay.

This deficiency represents non-compliance investigated under Master Complaint Number 2789590 and Complaint Number 2785293.