A resident with polyarthritis, left shoulder replacement, and chronic pain had physician orders and a care plan specifying multiple non-pharmacological pain interventions, including massage, positioning, ice therapy, relaxation, and diversional activities. Pain assessments showed frequent pain, with very few zero-pain readings, yet review of the MAR revealed that no non-pharmacological interventions were documented as provided throughout the stay. In interviews, a PA stated such interventions should be offered for pain, and an LPN, a unit manager, the DON, and the ADON all confirmed that these ordered non-pharmacological interventions were not implemented despite the resident’s repeated and almost constant pain complaints, contrary to the facility’s pain management policy.
A resident with multiple chronic conditions, cognitive impairment, and documented daily pain was admitted with orders for PRN Tylenol and every-shift pain assessments, along with a baseline care plan directing staff to monitor verbal and non-verbal pain signs and medicate per orders. Facility records showed that required pain assessments were repeatedly not completed on several shifts, and when pain scores of three and four were documented, there was no evidence that any pharmacologic or non-pharmacologic pain interventions were offered or provided. The resident’s family later reported the resident had been in pain and unwell, and increased pain complaints were eventually reported to an NP, but the Regional Nurse Consultant confirmed that pain relief was not offered at admission or when pain was documented, contrary to the facility’s pain assessment and management policy.
A resident with chronic pain and multiple comorbidities was ordered scheduled Lyrica and Robaxin for pain, but staff failed to assess and document pain levels before and after medication administration over several months. MARs for multiple months lacked any pain scores or effectiveness documentation, and the resident reported ongoing pain rated 6–7/10 and stated no one had asked about pain since admission. The DON acknowledged unawareness of the resident’s kidney stone and unrelieved pain and confirmed that nurses did not document pain levels as expected, while the CNP confirmed staff did not communicate the resident’s pain levels or the ineffectiveness of the current pain regimen, contrary to the facility’s pain assessment policy.
A resident with arthritis and other chronic conditions had a physician’s order for Tramadol 50 mg TID for pain, but the facility failed to provide the medication as ordered over several days. Narcotic logs and pharmacy records showed the Tramadol supply was exhausted and not replenished for multiple days, while the MAR inconsistently documented some doses as given and others as not administered. Nursing notes indicated the drug was on order or on hold and that an NP was notified of missed doses, but there was no documented order to hold the medication and no documentation on some days about the unavailability. The resident, who was cognitively intact, reported not always receiving medications as ordered, and the DON confirmed that Tramadol was not available during part of the period despite MAR entries indicating administration.
A resident with metastatic cancer and chronic severe pain had an MDS indicating almost constant pain rated at eight and a care plan calling for monitoring and physician notification of unrelieved pain, but pain management remained PRN oxycodone every four hours and a weekly buprenorphine patch. The resident was frequently observed and reported as being in significant pain, with a swollen, painful ankle and repeated requests for pain medication every two to three hours, including immediately upon waking. The resident’s daughter reported that the resident missed doses while asleep and had asked staff to have the pain medication scheduled, but no change was made. Multiple CNAs and LPNs confirmed frequent high pain scores and regular PRN use, yet none contacted the provider or requested scheduled dosing, and leadership (a unit manager and the DON) were unaware of the frequency of requests or the daughter’s concerns. Review of hospital discharge paperwork showed an oxycodone order every three hours PRN, while the continuity of care form listed every four hours PRN, a discrepancy the DON acknowledged needed clarification, and the facility’s own pain policy calling for individualized, potentially around-the-clock analgesia was not followed.
A resident with multiple medical conditions, including a displaced fracture of the upper left humerus, was admitted with hospital orders for PRN oxycodone for pain. Facility physician orders continued PRN oxycodone for fracture-related pain, but due to the prescription being sent to a specialty pharmacy without a required signature, the medication was not available for approximately 36 hours. During this time, the resident reported excruciating pain, and the MAR showed the first oxycodone dose was not given until two days after the facility order, with a documented pain level of nine. This failure to ensure timely availability of ordered PRN pain medication resulted in a deficiency related to pain management.
A resident admitted with multiple medical conditions and a recent abdominal surgery had a hospital discharge prescription for PRN oxycodone for severe pain, reported ongoing sharp pain affecting sleep, mood, ADLs, and mobility, and was care planned for pain management. However, the resident did not receive any PRN pain medication, pain levels were not documented on the TAR despite required shift assessments, and the MDS reflected no scheduled or PRN pain use. Nursing staff repeatedly attempted to fax the oxycodone prescription to the pharmacy, which reported not receiving it, and the Regional Clinical Director later confirmed that the resident had no PRN pain medication available and did not receive appropriate pain monitoring, despite the ability to obtain authorization from emergency supply with a paper prescription.
A resident with dementia, Wernicke's encephalopathy, and psychotic disorder was care planned as being at risk for pain and had scheduled Tylenol ordered for left hip pain, with an MDS indicating occasional pain that interfered with sleep. Despite a facility policy requiring every-shift pain monitoring documented on the MAR flow sheet and the DON’s expectation that all residents have a set day for pain assessments, the resident’s MARs for multiple months contained no order for routine pain monitoring and no documented pain assessments after a specific date. The resident reported fluctuating but manageable pain controlled by scheduled medication, but staff failed to consistently assess and record pain levels as required by the care plan and facility policy.
A resident with acute kidney failure, kidney stones, UTI, moderate cognitive impairment, and severe left hip osteoarthritis experienced inadequate pain management when PRN acetaminophen and later PRN oxycodone were not used or escalated in a timely and consistently effective manner. On one occasion, the resident was documented as yelling with pain rated 9/10, initially receiving only Tylenol because narcotics were noted as not due, and although oxycodone was later increased and administered, the resident was again observed yelling in pain that same afternoon. A family member reported the resident screaming in pain on another day, being told that Tylenol would not be available for some time, and that the nurse would not call the NP or physician, instead waiting for the NP’s next visit and only leaving a log-book message. These events occurred despite facility policies requiring prompt physician notification for changes in condition and pain management consistent with professional standards.
A resident with dementia, RA, disc degeneration, and neuropathy received frequent PRN oxycodone for pain, but the record showed no evidence that non-pharmacological interventions were attempted before the doses were given. The care plan included trying non-medication interventions if the resident allowed, and an LPN confirmed that such interventions should be attempted before administering PRN pain medication.
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