F0641

D

Inaccurate MDS Pain Management Assessment for a Resident

Kerrville, Texas Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that a resident’s Minimum Data Set (MDS) assessment accurately reflected the resident’s pain management status. The quarterly MDS submitted on 1/1/2026 for Resident #1 documented in section J0100 that the resident had not received a scheduled pain medication regimen and had not received or been offered PRN pain medications in the prior five days. This documentation conflicted with the resident’s medical record, which showed active physician orders for multiple scheduled and PRN pain medications, including acetaminophen PRN, methocarbamol scheduled at bedside and PRN, pregabalin three times daily for drug-induced polyneuropathy, and tramadol at bedtime for pain. The resident’s care plan also identified acute pain and osteoporosis, with an intervention to give analgesics PRN for pain.

Resident #1 was a female with diagnoses including unspecified pain and drug-induced polyneuropathy, and her quarterly MDS reflected a BIMS score of 14, indicating intact cognition. In an interview, she reported having neuropathy, taking Lyrica (pregabalin) and tramadol on a scheduled basis three times a day, and using additional PRN doses several times a week, stating that this regimen had been consistent for several years and effectively controlled her pain. The MDS nurse stated she was primarily responsible for MDS completion but had been out on leave and did not complete the 1/1/2026 MDS for this resident. After reviewing section J0100, she acknowledged that it contained inaccurate information and stated that the MDS should be completed accurately in accordance with the facility’s comprehensive assessment policy and for accurate reimbursement and evaluation of residents’ long-term needs.