Failure to Offer and Document Non-Pharmacological Pain Interventions: A resident with metastatic prostate cancer and neoplasm-related pain received frequent PRN hydromorphone and other PRN pain meds, but staff did not offer, implement, or document non-pharmacological pain interventions before or after administration. The resident stated massage had helped in the past but had not been offered, and staff interviews confirmed they were expected to document interventions and their effectiveness, yet no individualized non-pharmacological pain measures were identified in the care plan.
A facility failed to assess pain and failed to offer or document non-pharm interventions before giving PRN pain meds to three residents. One resident had pain affecting sleep, therapy, and ADLs; another had mild pain affecting sleep and therapy; and a third had pain with a care plan that did not identify non-pharm measures. Progress notes for PRN oxycodone-acetaminophen and methocarbamol did not include pain location or any attempted non-pharm interventions, despite staff stating pain location, severity, and non-pharm measures should be assessed and documented.
A resident with chronic left elbow pain, spinal stenosis, and other comorbidities had repeated PRN oxycodone administrations for severe breakthrough pain, but the pain regimen was not consistently re-evaluated and documentation was often incomplete or missing. Staff frequently recorded the medication as ineffective or unknown, with pain remaining high, while non-pharmacological measures were inconsistently documented and an RN did not complete a full pain assessment when the resident was visibly crying and moaning in pain.
Failure to Administer Ordered Pain Medication: A resident with multiple chronic conditions and ongoing LLE pain did not receive newly ordered hydromorphone for pain control after oxycodone was discontinued. The MAR showed no hydromorphone doses were administered, the order was not timely transcribed, and the record did not show assessment of pain relief or the resident’s response after PRN pain meds were given before transfer for pain control.
A resident with severe cognitive impairment and orders for lidocaine to be applied before a daily enoxaparin injection experienced pain when staff did not follow the order consistently. A family member reported the lidocaine was sometimes applied after the injection or not at all, and an LPN and RN both administered injections without first applying the topical anesthetic, leading to the resident screaming, resisting care, and striking out at staff. The DON stated nurses were expected to review orders before giving medications, and that applying lidocaine after the injection would not relieve the pain from the injection.
A resident with multiple pain-related conditions, including neuropathy, fracture, and chronic wounds, had care plans and PRN orders for various analgesics and non-pharmacological interventions, but the plan did not specify an acceptable pain level or clearly direct which analgesic to use before wound treatments. Records showed no comprehensive assessment or specific interventions for preventing pain during wound care, and on one morning only aspirin was given despite a documented pain level of 6, with no evidence that other ordered PRN pain medications or non-pharmacological measures were offered. During an observed buttock dressing change, the resident repeatedly yelled and verbalized pain while being turned and treated, and pain medication was not offered before the procedure began. Staff interviews confirmed the resident frequently screamed in pain with repositioning, that PRN medications were often given only if requested or directed, and that the LPN and DON later acknowledged that stronger pain medication and earlier intervention should have been used based on the facility’s pain scales and the resident’s reported pain levels.
A resident with multiple serious medical conditions and intact cognition received PRN Oxycodone on several occasions without documentation of the specific pain indication, symptoms, or non-pharmacologic interventions attempted prior to administration. Although the care plan and facility staff (including an LPN, RN, NP, and DON) described an expected process of assessing pain using a 0–10 scale, identifying pain location and characteristics, offering measures such as repositioning, ice, heat, food, or distraction, and then documenting the PRN narcotic administration and its effectiveness, the MAR and progress notes lacked this required information. The facility’s own Medication Administration policy requiring documentation of complaints or symptoms, date and time, dose, route, and results of PRN medications was not followed for these Oxycodone doses.
A resident admitted with a history of chronic pain from transverse myelitis and long-term opioid use reported ongoing moderate to severe pain that interfered with sleep and daily activities, but arrived without an order for her usual Percocet. Although PRN oxycodone-acetaminophen and a lidocaine patch were later ordered and administered for pain scores up to 9/10, nursing notes and the MAR did not document the use of non-pharmacological interventions such as repositioning, rest, or other comfort measures, despite these being listed on the care plan and required by facility policy. The baseline care plan initially lacked specific pain-relief interventions, and staff interviews, including with the DON, confirmed that expected pain assessments, non-medication strategies, and documentation of interventions and resident responses were not completed for this resident.
A resident admitted for post-surgical care after cervical spinal fusion, with intact cognition and a history of spinal stenosis, experienced severe, constant pain that was not managed in a timely manner. Although orders and the care plan called for pain monitoring every shift, PRN acetaminophen and oxycodone, and non-pharmacological interventions, documentation showed no acetaminophen given, delayed initiation of oxycodone until more than a day after admission, and minimal non-pharmacological measures despite pain ratings of 7/10 or higher. Family reported the resident had pressed the call light and remained in severe pain without relief, and staff interviews revealed the ordered oxycodone was not available on admission due to miscommunication, despite the ability to obtain narcotics from the facility’s medication bank. The DON and other clinicians acknowledged that the established pain management process and protocol, including timely assessment, medication availability, and provider notification when medications were delayed, were not followed for this resident.
A resident with chronic pain syndrome, amputation, shrapnel‑related osteoarthritis, and PTSD was on scheduled morphine IR with a PRN order. Staff failed to timely re‑order and ensure availability of the scheduled morphine, resulting in four missed doses and a prolonged gap in full opioid coverage. During this period, the resident reported pain escalating from a baseline 5/10 to 10/10, remained in bed, had decreased appetite, increased anxiety, sweating, and confusion, while his spouse observed him quiet, diaphoretic, and unable to operate the TV remote. Nursing documentation between the missed doses lacked comprehensive pain assessments with pain characteristics, non‑pharmacologic interventions, increased monitoring for escalating pain or opioid withdrawal, or consideration of emergency transfer. One RN recognized in advance that the morphine supply would be insufficient but did not contact the provider due to time constraints, subsequent nurses confirmed the missed doses and significant pain, and the DON was not notified and did not become aware until later. The NP did not verify that the prescription reached the pharmacy, did not provide alternate pain management orders, and did not direct staff to monitor for withdrawal. The facility’s pain management policy required ongoing assessment and reassessment but did not specify when to complete comprehensive assessments, how to document baseline pain, or what steps to take when scheduled pain medications are missed or unavailable, contributing to the deficient pain management.
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