Failure to Provide Effective, Multimodal Pain Management
Summary
Facility staff failed to ensure effective pain management for a resident with chronic pain syndrome related to degenerative disc disease of the lumbar spine and avascular necrosis of the left hip. The resident’s care plan identified bilateral hip pain and neuropathic pain, with goals for the resident to verbalize relief of pain, cope with and complete activities with pain relief, and remain free from interruption in normal activities due to pain. Interventions in the care plan focused on administering analgesics as ordered, anticipating the resident’s need for pain relief, responding promptly to complaints of pain, and evaluating the effectiveness of pain interventions, including reviewing compliance, symptom alleviation, dosing schedules, resident satisfaction, and impact on function and cognition. However, the care plan, initiated in April 2024 and last revised in December 2025, did not include any non-pharmacological interventions to assist with alleviating the resident’s pain. Clinical record review showed multiple episodes of uncontrolled pain despite ongoing pharmacologic management. A nursing note documented that staff were called to the resident’s room for increased, uncontrolled pain with a reported pain score of 10/10, and the physician assistant provided a one-time order for hydrocodone/acetaminophen 10-325 mg. Subsequent progress notes indicated chronic pain syndrome with ongoing symptom review and pain described as only partially controlled, with continued reports of uncontrolled pain and pain ratings up to 10/10. Although analgesic dosages were adjusted over time, there was no evidence in the record that non-pharmacological or alternative pain management approaches were implemented or documented to help alleviate the resident’s pain. Staff interviews further illustrated issues with the resident’s pain management and staff response. An LPN reported that the resident was sometimes rude and disrespectful, and stated that staff ignored and avoided the resident’s room because of how he spoke to people. The assistant DON reported that the resident refused care daily due to pain, screamed out when his left leg was moved, and declined care, assistance, and appointments because of pain, while also requesting increased pain medication dosages and medical marijuana. The MDS coordinator explained that care plans should be updated with changes in condition or ineffective interventions, and that interventions should be changed if not effective, but there was no indication that non-pharmacological interventions were added to the care plan despite ongoing uncontrolled pain. The facility’s own pain management policy required pain management consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident’s goals and preferences, but documentation and interviews showed that non-pharmacological pain interventions were not developed or implemented for this resident.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident recovering from a recent below-the-knee amputation experienced severe pain when their prescribed Oxycodone was not renewed in time, leaving no narcotic pain medication available. Despite repeated reports of high pain levels and a care plan identifying pain risk, the on-call NP declined to renew the prescription overnight, offering only extra strength Tylenol, which the resident refused. The resident was ultimately transferred to the hospital for pain control.
A facility failed to maintain the availability of pain management medications for a resident, leading to a deficiency in care. The resident, with multiple health issues, was without a Fentanyl patch for several days due to a lapse in obtaining a new prescription. Despite efforts by an RN to contact the pharmacy and request a new prescription, the facility did not secure the necessary order in time, resulting in the resident experiencing continuous pain.
The facility failed to provide timely and appropriate pain management for two residents. One resident with a stage III pressure ulcer experienced severe pain during care without adequate intervention, while another resident reported severe shoulder pain after a Hoyer lift incident, which was not documented or promptly addressed. The facility's pain management policy was not followed, leading to prolonged discomfort for the residents.
A resident with multiple vascular wounds on her lower extremities did not receive adequate pain management in a timely manner. Despite having a care plan, the facility failed to assess and treat the resident's pain effectively, particularly during dressing changes. The resident frequently reported high levels of pain, but pain assessments and timely administration of pain relief were lacking, as confirmed by staff interviews and observations.
A resident with chronic pain conditions did not receive pain medication as ordered due to an unfamiliar ADON working the floor. The resident, who was supposed to receive hydromorphone every four hours, waited over an hour for relief, causing distress. The Unit Manager intervened after concerns were raised, highlighting a failure to adhere to the facility's pain management policy.
The facility failed to provide adequate pain management for two residents, resulting in actual harm. One resident, admitted with chronic pain, did not receive their prescribed opioid medication, leading to severe pain and limited functional abilities. Another resident with a history of cerebral infarction experienced inadequate pain assessments and inconsistent medication administration, limiting their functional activities. The facility's pain policy was not followed, resulting in prolonged discomfort for the residents.
Failure to Provide Timely Post-Surgical Pain Management
Penalty
Summary
A deficiency occurred when a resident who had recently undergone a below-the-knee amputation was not provided with adequate post-surgical pain management. The resident had a physician's order for Oxycodone 10 mg every four hours as needed for moderate pain, and acetaminophen scheduled every eight hours. The resident consistently reported significant pain, with pain levels ranging from 7 to 10, and had received 17 doses of Oxycodone prior to the incident. The care plan identified the resident as being at risk for pain due to the recent surgical procedure, with interventions including medication and repositioning. On the night of the incident, the resident experienced severe pain rated at 10 out of 10 and requested narcotic pain medication. However, the Oxycodone prescription had expired and was not renewed in a timely manner, resulting in no narcotic pain medication being available. The on-call nurse practitioner declined to renew the prescription during the night and instead ordered extra strength Tylenol, which the resident refused. As a result, the resident requested transfer to the hospital for pain management and was subsequently transported by EMS. Interviews with staff confirmed that the failure to renew the Oxycodone prescription led to the unavailability of the medication when the resident was in severe pain. The DON acknowledged that the prescription had expired and was not renewed, which directly resulted in the resident's transfer to the hospital for pain control. The facility's pain management policy defined pain management as alleviating pain to a level acceptable to the resident, but this standard was not met in this case.
Plan Of Correction
This Plan of Correction is being prepared and executed because it is required by the provisions of the State and Federal regulations and not because Kingston of Ashland agrees with the allegations and citations listed on the statement of deficiencies. Kingston of Ashland maintains that the alleged deficiencies do not individually or collectively jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as Kingston of Ashland's written credible allegations of compliance. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Kingston of Ashland reserves all possible contentions and defenses in any civil or criminal actions or proceeding. Please accept the date of correction 4/17/2025 as the facility's credible allegation of compliance. F697 Resident #93 no longer resides in the center. Resident #93 was sent to the ER on 3/7 and script for Percocet obtained at that time. Nurse practitioner #339 was provided education on 4/3 and 4/4 on the pain assessment and management policy, controlled substance prescription policy, and receiving controlled substances policy. The Director of Nursing or designee will review current residents on narcotic pain medications to ensure that the narcotic medication regimen is effective for treating pain and that the narcotic pain medications are available for use. This will be completed on or before 4/17/2025. Issues identified will be addressed at the time of discovery. The Director of Nursing or designee will educate licensed nurses and Certified Medication Aides on the controlled substance prescription policy and receiving controlled substance policy, which includes reordering of controlled medications, on or before 4/17/2025. The Director of Nursing or designee with educated licensed nurses on the pain assessment and management policy on or before 4/17/2025. The Director of Advanced Nurse Practitioners will educate the nurse practitioners on the controlled substance prescription policy and receiving controlled substance policy, which includes reordering of controlled medications, on or before 4/17/2025. The Director of Nursing or designee will complete an audit on 5 residents weekly for 4 weeks that receive narcotic pain medications to ensure that the narcotic medication regimen is effective for treating pain and that narcotic pain medication is available for use. The results will be presented to the QAA committee for review and consideration for further corrective actions.
Failure to Maintain Pain Management Medication Availability
Penalty
Summary
The facility failed to maintain the availability of ordered pain management medications for a resident, leading to a deficiency in providing safe and appropriate pain management services. Resident #33, who was admitted with multiple diagnoses including acute respiratory failure, cellulitis, dysphagia, and chronic congestive heart failure, was cognitively intact and experienced mild depression. The resident had orders for a Fentanyl patch to be changed every 72 hours and Oxycodone as needed for pain. However, the resident reported experiencing continuous pain and went without the Fentanyl patch for 10-12 days due to issues with prescription refills. The March 2025 medication administration record indicated that Resident #33 was without a Fentanyl patch from March 9 to March 14. A progress note from March 6 documented that RN #47 contacted the pharmacy for a refill, but was informed that a new prescription was needed. Despite a request being placed on the physician's medication refill voicemail, the facility did not obtain a current order from the physician until March 14. The Director of Nursing confirmed the lapse in obtaining the necessary prescription, resulting in the resident not receiving the Fentanyl patch during this period.
Inadequate Pain Management for Two Residents
Penalty
Summary
The facility failed to provide timely and appropriate pain management for two residents, Resident #6 and Resident #7, as identified through interviews, observations, and record reviews. Resident #7, who was admitted with diagnoses including diabetes mellitus, a stage III pressure ulcer, and chronic pain, experienced significant pain that was not adequately addressed during care. Despite receiving scheduled pain medications, Resident #7 reported severe leg pain during an interview and was observed to be in distress during a dressing change, with no additional pain relief interventions offered by the staff at that time. Resident #6, admitted with conditions such as cerebral infarction and hemiplegia, also experienced inadequate pain management. The resident reported severe shoulder pain following an incident with a Hoyer lift, which was not documented in the facility's incident log. Despite a high pain rating and complaints of pain affecting daily activities, there was a delay in obtaining an x-ray and providing appropriate pain relief. The resident's pain was not adequately assessed or managed, leading to prolonged discomfort and anxiety. The facility's policy on pain assessment and management, revised in October 2022, outlines procedures for identifying and addressing pain, including the use of both pharmacological and non-pharmacological interventions. However, the facility failed to adhere to these procedures, resulting in inadequate pain management for the residents. The lack of timely assessment and intervention for acute pain episodes contributed to the deficiencies identified in the report.
Inadequate Pain Management for Resident with Vascular Wounds
Penalty
Summary
The facility failed to implement an effective pain management program for a resident with multiple vascular wounds on her lower extremities. The resident, who was cognitively intact, had a history of peripheral vascular disease, major depressive disorder, type two diabetes, and heart failure. Despite having a care plan that included administering analgesia and monitoring pain, the facility did not adequately assess or treat the resident's pain prior to wound care treatments. The resident's medical records revealed multiple instances where pain assessments were not conducted, and pain medication was not administered in a timely manner. The resident frequently reported pain, especially during dressing changes, but there was no documented evidence of pain assessments or administration of pain relief prior to these procedures. The resident's pain was often rated high on a scale of zero to ten, yet the facility failed to provide consistent pain management. Interviews with staff and observations confirmed that the resident experienced significant pain, particularly during wound care. Staff members acknowledged the resident's complaints of pain and the ineffectiveness of the current pain management approach. The facility's policy on administering pain medications emphasized the importance of assessing pain and recognizing non-verbal signs, but these guidelines were not followed, leading to inadequate pain management for the resident.
Failure to Administer Pain Medication Timely
Penalty
Summary
The facility failed to administer pain-relieving medications as ordered for a resident with chronic pain conditions, including Crohn's disease and intervertebral disc degeneration. The resident, who had intact cognition, was supposed to receive hydromorphone every four hours as needed for pain. On the day in question, the Assistant Director of Nursing (ADON) was working the floor due to a staff call-off and was unfamiliar with the medication administration on that unit. The ADON did not administer the pain medication in a timely manner, causing the resident to wait at least an hour for relief, despite the resident's request and visible distress. The incident was investigated after concerns were raised by staff, residents, and family members about the delay in medication administration. The Unit Manager took over the medication administration from the ADON and provided the resident with the overdue hydromorphone. The facility's policy on pain management and assessment requires staff to ensure residents receive treatment and care in accordance with professional standards, which was not adhered to in this case. This deficiency was investigated under a specific complaint number, indicating non-compliance with the facility's pain management protocols.
Inadequate Pain Management for Residents
Penalty
Summary
The facility failed to provide adequate pain management for two residents, resulting in actual harm. Resident #273 was admitted with a history of chronic pain and an active order for Norco, an opioid pain medication, from a previous facility. However, upon admission, the facility did not continue the Norco order, and the resident was not evaluated by a physician in a timely manner. As a result, the resident experienced severe, constant pain that limited his functional abilities and participation in therapy. Despite expressing pain and refusing Tylenol, which was ineffective, the resident did not receive appropriate pain management until several days later when Tramadol was prescribed. Resident #66, who had a history of hemiplegia and other conditions following a cerebral infarction, also experienced inadequate pain management. The resident's care plan included interventions for pain, but there were multiple instances where pain assessments were not conducted, and pain medication was not administered as needed. The resident's pain was documented during therapy sessions, where it was noted to limit functional activities, yet the facility failed to consistently address and manage the pain effectively. Observations revealed the resident exhibited signs of pain during transfers and therapy, but these were not adequately documented or addressed by the nursing staff. The facility's failure to implement a comprehensive and individualized pain management program for these residents was evident in the lack of timely physician evaluation, inadequate pain assessments, and inconsistent administration of pain medication. The facility's pain policy, which required assessments and interventions for identified pain, was not followed, leading to prolonged discomfort and limited functional abilities for the affected residents.
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