F0697

J

Failure to Provide Ordered Pain Medication and Notify Provider of Uncontrolled Pain

Texarkana, Texas Survey Completed on 03-06-2026

Penalty

Fine: $127,250

Summary

The deficiency involves the facility’s failure to provide safe, appropriate, and consistent pain management to a cognitively intact male resident with chronic pain who was admitted with diagnoses including age-related physical disability, hypertension, schizophrenia, and major depressive disorder. His MDS showed he was able to make himself understood, understood others, and was on scheduled pain medication. He had a physician’s order for Hydrocodone-Acetaminophen 10-325 mg by mouth three times daily, and his care plan directed staff to give pain medication and evaluate his pain so that he would remain free from pain. Despite these orders, the Medication Administration Record (MAR) for two consecutive months showed multiple scheduled doses at 7:00 AM, 12:00 PM, and 5:00 PM documented as not administered, with reasons such as “other/see progress note,” and repeated administration notes stating the hydrocodone was “waiting on arrival,” “on order,” or “N/A.”

During the period when the medication was unavailable, there was no documentation in the resident’s progress notes that the physician, nurse practitioner, or pharmacy had been notified that the resident was out of his ordered hydrocodone. A Triplicate Request form for the hydrocodone contained an undated, unsigned handwritten note indicating a new triplicate was required because the facility had changed pharmacies, but there was no corresponding documentation of timely follow-up or communication with the prescriber. The resident reported that he had gone without his pain medication for about five days, that he was told his pain medication was not in the building, and that he was not informed why he could not have it. He described excruciating back and neck pain, inability to sleep or rest, numbness in his hands and fingers, and rated his pain as greater than 10 on a 1–10 scale. He stated he was not offered any other pain medication and that non-pharmacologic measures such as repositioning and pillow adjustment were offered but refused because he wanted his prescribed pain medication.

Multiple staff interviews revealed awareness that the resident’s hydrocodone was not available and that doses were being missed, but there was a lack of effective action and documentation to resolve the issue. An anonymous staff member and a medication aide stated they had informed charge nurses and the ADON that the resident’s pain medication was unavailable and that the resident was frustrated and distraught due to uncontrolled pain, yet the nurse practitioner reported she was never notified of the missed doses or change in the resident’s condition until weeks later. The ADON acknowledged knowing the resident had missed doses, stated she had called and faxed the pharmacy and contacted the nurse practitioner about triplicates, but admitted she had not documented any of these efforts or any notification to the physician or nurse practitioner about the missed medications. The charge nurse (LVN) on duty during part of the period admitted she knew the resident did not have his ordered hydrocodone, did not reassess his pain, did not offer alternative pain-relieving medications, and could not recall notifying the nurse practitioner. Pharmacy records showed only one facility request for hydrocodone and a subsequent supply, with no further logged activity until much later, indicating a lack of documented follow-up from the facility. These combined inactions and communication failures led to the resident going without his ordered scheduled pain medication and experiencing uncontrolled, excruciating pain with behavioral changes, while the facility failed to manage his pain consistent with professional standards of practice.