Failure to Provide Ordered Tramadol for Pain Management
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident with chronic pain needs. The resident, admitted with diagnoses including diabetes mellitus, hypertension, depression, anxiety, and arthritis, had a care plan identifying altered comfort related to arthritis and directing staff to administer medications as ordered. A physician’s order dated 12/27/25 prescribed Tramadol 50 mg three times daily. Review of the narcotic log for February 2026 showed the resident’s last available Tramadol dose was given on 02/13/26 at 6:00 P.M., with no further Tramadol available until 02/17/26 at 2:00 P.M. The MAR documented multiple scheduled Tramadol doses as not administered on 02/14/26 (morning and 3:00 P.M.), 02/15/26 (8:00 P.M.), and 02/16/26 (morning and 3:00 P.M.), despite the standing TID order. Nursing progress notes on 02/14/26 and 02/16/26 indicated the nurse was waiting on Tramadol from the pharmacy and that it was on order or on hold until available, and that the nurse practitioner had been made aware of missed doses, but there was no documentation of any order to hold the medication. Further record review and interviews confirmed that Tramadol was not available in the facility for this resident between 02/14/26 and 02/16/26 until 8:00 P.M. on 02/16/26, even though the MAR reflected administration on 02/14/26 at 8:00 P.M. and on 02/15/26 in the morning and at 3:00 P.M. Pharmacy records showed only two Tramadol deliveries for this resident during the relevant period, on 01/31/26 and 02/16/26, with no additional supply sent between those dates. The resident, who had intact cognition and no behaviors per the most recent MDS, reported that she did not always receive her medications as ordered and that medications were sometimes missed or late. The Interim DON verified that the resident did not receive Tramadol as ordered on the identified dates and that the medication was not available during part of the period in question, despite documentation indicating it had been administered. Facility policies on Medication Administration and Management and Pain Management required nursing staff to administer medications as ordered and to document medication unavailability, but the documentation and medication supply did not align with those requirements.
Penalty
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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 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 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.
Failure to Implement Ordered Non-Pharmacological Pain Interventions
Penalty
Summary
Surveyors identified that the facility failed to follow physician orders for non-pharmacological pain interventions for one resident who required pain management services. The resident was admitted with diagnoses including polyarthritis, anxiety disorder, unspecified shoulder pain, hypertension, and diastolic heart failure, and had moderately impaired cognition. The care plan, dated 03/11/26, documented that the resident was at risk for pain and/or had acute pain related to a left shoulder replacement and chronic pain related to polyarthritis, with interventions directing staff to notify the physician if interventions were unsuccessful or if the pain complaint significantly changed from the resident’s past experience. Provider orders dated 03/11/26 specified multiple non-pharmacological pain interventions, including massage, meditation, relaxation, positioning, ice therapy (20 minutes every hour), diversional activity, guided imagery, rest, and social interaction. Review of the pain level summary from admission to discharge showed that out of 163 pain assessments, the resident reported a pain level of zero only 11 times, indicating frequent pain complaints. Review of the Medication Administration Records revealed that no non-pharmacological pain interventions were documented as provided at any time during the resident’s stay. In interviews, the physician assistant stated that non-pharmacological interventions should be completed or offered to residents with pain. An LPN and the unit manager both confirmed that non-pharmacological interventions were not done or offered when the resident reported pain. The DON and ADON further acknowledged that the resident had repeated and almost constant complaints of pain and that non-pharmacological interventions should have been offered but were not. The facility’s pain management policy, dated 03/05/25, stated that staff will implement the care plan, monitor residents, and administer therapeutic interventions for pain, which was not followed in this case.
Failure to Provide Ordered Pain Assessment and Management for a Resident with Chronic Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate pain management for Resident #93, who was admitted with multiple significant diagnoses including cerebral infarction, dysphagia, diabetes, morbid obesity, sepsis, bipolar disorder, anxiety disorder, hypertension, osteoarthritis, thoracic spine pain, and peripheral vascular disease. On admission, the clinical assessment documented impaired short- and long-term memory, orientation only to self, daily pain with a pain level of three on a 0–10 scale, and non-verbal expressions of pain, yet there was no evidence that any pain relief interventions were offered or provided. The baseline care plan set a goal to promote the resident’s comfort over 30 days and included approaches such as monitoring verbal and non-verbal pain signs, working with therapy for pain control, medicating per orders based on pain indications, and reporting unrelieved pain to the physician. Physician orders dated 01/24/26 included Tylenol 1000 mg every six hours as needed and an order to assess pain every shift using a 0–10 pain scale. Record review showed that every-shift pain assessments were not consistently completed as ordered: they were missing on several night shifts in January and February and on one day shift in January. When pain assessments were documented, they showed pain levels of three and four on specific shifts, but there was no evidence that the resident was offered or given any interventions for pain relief in response to these findings. A nursing note documented that the resident’s daughter reported the resident had been in pain, nauseous, and not feeling well during a visit, although the resident did not express pain at the time of the subsequent assessment and was oriented only to person, which the daughter stated was her new baseline. Later, increased complaints of pain were reported to the nurse practitioner, who ordered scheduled Tylenol and subsequently assessed the resident and ordered transfer to the hospital after the resident was noted to be minimally responsive with tremors. The Regional Nurse Consultant confirmed that the resident was assessed on admission with a pain level of three without any evidence that pain relief was offered, that every-shift pain assessments were not completed as ordered, and that nothing was offered or given when pain was identified on the MAR. The facility’s pain policy required assessment, monitoring, treatment, and evaluation of pain, and treatment of residents identified as experiencing pain in accordance with their care plan, including use of non-pharmacological interventions when appropriate.
Failure to Assess and Document Pain and Effectiveness of Analgesics
Penalty
Summary
The deficiency involves the facility’s failure to routinely assess, document, and monitor pain and the effectiveness of pain medications for a resident on a pain management program. The resident was admitted with diagnoses including acute pyelonephritis, bladder and kidney calculi, chronic kidney disease, and type 2 diabetes mellitus, and had physician orders for Lyrica 50 mg twice daily for chronic pain syndrome and Robaxin 500 mg four times daily for pain. The MDS showed the resident had intact cognition and required staff assistance with ADLs. Review of the MARs for February, March, and April 2026 revealed no documentation of the resident’s pain level prior to administration of Lyrica and Robaxin and no documentation of the effectiveness of these medications in relieving the resident’s pain. During an interview, the resident reported a current pain level of six to seven on a 1–10 scale and stated that since admission no one had asked about her pain level. The DON confirmed she was unaware the resident had a kidney stone and had complained of unrelieved pain, and verified that nurses had not documented the resident’s pain level before and after administration of pain medications on the MARs for the reviewed months, despite the expectation that staff document pain level with each administration. The CNP confirmed that staff had not communicated the resident’s pain levels or that the current pain regimen was not effective. Review of the facility’s Pain Assessment and Management policy showed that staff were required to assess pain at least each shift for acute pain or significant changes in chronic pain, at least weekly for stable chronic pain, and to document the resident’s reported pain level with enough detail to gauge pain status and intervention effectiveness, which was not done in this case.
Failure to Ensure Availability and Monitoring of Prescribed PRN Pain Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with post-surgical pain had prescribed PRN pain medication available and appropriately monitored. The resident was admitted with multiple diagnoses including cellulitis, type II diabetes, morbid obesity, ventral hernia with obstruction, and venous thrombosis and embolism, and had an abdominal incision following surgery. The hospital discharge paperwork included a paper prescription for oxycodone 5 mg every six hours as needed for up to three days. On admission, the resident reported sharp pain rated 3/10, with a goal of 0, and the pain was documented as affecting sleep, mood, socialization, ADLs, physical activity, and mobility. An interim care plan and pain assessment documented that the resident was not cognitively impaired, had occasional pain that interfered with sleep and daily activities, and required pain medications. Despite this, the MAR showed the resident did not receive any PRN pain medication, and the MDS indicated the resident did not receive scheduled or PRN pain medication. The TAR required pain assessment and monitoring every shift, but while checkmarks were present for two shifts, the actual pain levels were not documented. Progress notes showed that the resident complained of pain and discomfort due to the abdominal incision after arrival and later became agitated, stating that night shift staff were not friendly or helpful. On a subsequent day, nursing staff contacted the pharmacy multiple times regarding the oxycodone prescription; the pharmacy reported not receiving the paper prescription, and the nurse faxed and re-faxed it three times. The Regional Clinical Director confirmed that the resident did not receive any PRN pain medication, did not have appropriate pain monitoring, that the hospital had sent a paper prescription, and that the pharmacy could have authorized oxycodone from the emergency supply with a paper prescription from the facility.
Failure to Adequately Manage Severe Cancer-Related Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate pain management for a resident with metastatic cancer and chronic severe pain. The resident was admitted with disseminated malignant neoplasm involving bone, genital organs, ovary, right lung, and intraabdominal lymph nodes, along with neoplasm-related pain, depression, anemia in neoplastic disease, muscle weakness, and unsteadiness. The admission MDS documented almost constant pain rated at eight, occasionally affecting sleep, and noted that the resident was receiving radiation. The care plan identified chronic pain due to metastatic cancer and included interventions to notify the physician of unrelieved or worsening pain and to provide information about pain management options and preferences. Medication orders included oxycodone 10 mg by mouth every four hours as needed for severe pain, an order to observe for pain every shift and document and treat it, and a weekly buprenorphine transdermal patch for pain. On observation, the resident was seen lying in bed with a red, puffy right ankle, tearful, pointing to the ankle and stating "pain." The resident’s daughter reported that when the resident was asleep, she missed her PRN pain medication, which was ordered every four hours, and stated that the resident had tumors in her ankle and lower back and should have scheduled pain medication. The daughter also stated that she had spoken to staff about scheduling the pain medication, but it had not been changed to a scheduled regimen. Multiple staff interviews confirmed that the resident frequently requested pain medication, often every two to three hours or as soon as she woke up, and that her reported pain scores were typically high (often 5–10) before medication and only decreased after receiving pain medication. Nursing staff, including CNAs and LPNs, acknowledged that the resident consistently requested pain medication, sometimes as often as every three hours, and that she rarely, if ever, reported a pain score of zero prior to medication. One LPN stated he did not contact the physician about the resident’s frequent pain or requests for medication. Other LPNs stated they did not consider asking for the pain medication to be scheduled or discussing this with anyone, despite the resident ringing her call light regularly for pain and having a diagnosis associated with significant pain. The Unit Manager stated she was not aware that the resident was requesting pain medication every three to four hours or that the daughter wanted the medication scheduled, and indicated that if the resident was requesting pain medication that frequently, the provider should have been notified. The DON stated she was not aware of the every-three-hour requests, acknowledged that the resident was receiving pain medication every four hours, and stated it would not have hurt to call the provider. Review of hospital discharge paperwork showed an oxycodone order for every three hours as needed, while the continuity of care form listed every four hours as needed, and the DON acknowledged this discrepancy required clarification. The facility’s own pain management policy called for recognizing and evaluating pain on admission and ongoing, managing pain consistent with assessment and care plan, and considering around-the-clock dosing or combining long-acting and PRN medications, but these steps were not implemented for this resident. This deficiency represents non-compliance investigated under Complaint Numbers 2899477 and 2800477.
Failure to Ensure Availability of Ordered PRN Pain Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure ordered pain medication was available for a resident who required pain management. The resident was admitted with multiple diagnoses, including discoid lupus erythematosus, depression, polyarthritis, cardiac arrhythmia, cervical disc disorder, a displaced fracture of the upper end of the left humerus, and rheumatic mitral stenosis. Hospital discharge orders dated 03/19/26 included Oxycodone immediate release 5 mg every four hours as needed. Facility physician orders dated 03/27/26 at 2:45 P.M. specified Oxycodone 5 mg orally every six hours as needed for pain related to the displaced fracture of the left humerus. Review of the MAR showed that Oxycodone was first administered on 03/29/26 at 8:55 A.M., at which time the resident’s pain level was documented as nine. The resident reported during interview that upon admission she experienced excruciating pain and was unable to receive Oxycodone, stating the facility could not provide it for 36 hours. The DON confirmed that the resident arrived with an Oxycodone order from the hospital and that the prescription was sent to the specialty pharmacy without a signature, resulting in the ordered Oxycodone not being available from 03/27/26 to 03/29/26. During this period, the resident did not have access to the prescribed pain medication. The facility’s pain assessment and management policy, dated 08/2025, directed staff to review the MAR to determine how often an individual requests and receives PRN pain medication and the extent to which administered medications relieve the resident’s pain. This deficiency was investigated under Complaint Numbers 2788877 and 2722512.
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