**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to manage pain consistent with the comprehensive assessment, plan of care, and physician's orders and to ensure potential acute opioid withdrawal symptoms were assessed to prevent avoidable, significant, pain for 1 of 1 resident (R23) reviewed for pain management. This deficient practice caused actual harm for R23, who experienced unmanaged pain and withdrawal symptoms. Findings include: R23's face sheet printed 10/31/24, indicated R23 had diagnosis of chronic pain syndrome with chronic opioid use related to a motor vehicle accident (MVA). R23's quarterly minimum data set (MDS) dated [DATE], indicated R23 was cognitively intact with no rejection of care. The MDS further indicated R23 had pain, however, did not receive any non-pharmacological interventions for pain. R23's pain Care Area Assessment (CAA) dated 5/7/24, indicated R23 reported pain which interfered with sleep and daily activities on an almost constant basis. Further, R23 reported constant pain rated at a 10 out of 10 on a 0-10 pain scale. Additionally, the CAA indicated R23 was at risk for pain not being adequately relieved or managed with interventions for nursing to monitor pain, administer pain medications as ordered, and nursing to update provider on pain as necessary and when pain was not adequately relieved/controlled. R23's care plan with revision date 5/17/24, indicated R23 had potential for alteration of comfort related to chronic pain syndrome, right humerus, and femur fractures, and left gluteal wound with the following interventions: pain medication as ordered by medical doctor (MD) and provide non-medicinal forms of pain relief including positioning, rest, and massage. R23's goal was to have adequate relief from pain as evidenced by verbalization, and freedom from signs/symptoms of non-verbal indications of pain. R23's physician visit note dated 10/10/24, indicated R23 had been on long-term opioid pain medications since 7/25/22 due to a motor vehicle accident and R23 reported pain intensity was an 8 on a 0-10 pain scale due to a recent fall during physical therapy which resulted in a fractured hip and shoulder. Further indicated, the physician ordered Belbuca (a strong prescription pain medicine that contains an opioid Buprenorphine. It is used to manage severe pain that requires long term treatment) 600 microgram (mcg) buccal film twice a day. R23's physician orders dated 10/31/24, indicated R23 had the following orders: -Lyrica 150 milligrams (mg) three times a day with a start date of 9/18/24 and a stop date of 10/11/24. -Lyrica 175 mg three times a day with a start date on 10/11/24. -Belbuca 900 mcg buccal film twice a day with a start date on 9/18/24 and a stop date of 10/11/24. -Belbuca 600 mcg buccal film twice a day with a start date on 10/11/24. R23's medication administration record (MAR) dated October 2024, indicated R23 did not receive the Belbuca 600 mcg buccal film from 10/11/24 at 8:00 p.m. through 10/15/24 at 8:00 p.m., a total of 9 doses missed. The MAR further indicated R23 did not receive the Lyrica 175 mg from 10/11/24 at 8:00 p.m. through 10/14/24 at 12:00 p.m., a total of 9 doses missed. R23's progress note dated 10/14/24 at 3:46 p.m., indicated R23 had increased anxiety, agitation, fidgeting, and pacing. R23's progress note dated 10/14/24 at 10:12 p.m., indicated R23's pain medication wasn't available and exhibited withdrawal symptoms such as restlessness and agitation. Review of R23's progress notes from 10/10/24 through 10/15/24, revealed no indication of physician notification of missed pain medications, R23's pain status, or R23's withdrawal symptoms. During review of R23's electronic medical record (EMR) from 10/10/24 through 10/16/24 on 10/31/24, lacked indication of non-pharmacological interventions provided, physician notification, or new pharmacological orders provided in substitution. During an interview on 10/31/24 at 10:59 a.m., registered nurse (RN)-A stated R23's Belbuca 600 mcg and Lyrica 175 mg pain medications were not available. Further, RN-A stated R23 was miserable and a mess during the days the pain medications weren't provided. Additionally, RN-A stated R23 exhibited withdrawal symptoms of shakiness, irritability, and restlessness during the days the pain medications weren't provided. Also, RN-A stated R23 was allowed to go smoke after hours throughout the night while he was unable to sleep. During an interview on 10/31/24 at 11:35 a.m. R23 stated, I felt awful, my pain was through the roof, my pain was completely out of control and they didn't do anything for my pain. Further, R23 verified the facility staff did not provide any non-pharmacological interventions during the time the pain medications weren't provided. During an interview on 10/31/24 at 11:43 a.m., registered nurse manager (RN-B) stated was informed by the nursing staff the pharmacy didn't send the new prescribed medications due to it was too early to fill the medications so, the medical provider was contacted on 10/16/24 regarding the missing pain medications. RN-B further stated the issue was the previous Belbuca and Lyrica medications were destroyed since R23 was given new prescriptions for the Belbuca and Lyrica. Additionally, the Belbuca prescription was sent to the wrong pharmacy and the facility had to call and have the pharmacy release the prescription so the facility pharmacy could fill and send the medication. During an interview on 10/31/24 at 1:26 p.m. the DON verified the nurses should have called the pharmacy when the medication wasn't received and should have updated the physician right away if the pharmacy couldn't send the medication. During an interview on 10/31/24 at 1:30 p.m., pain specialty physician stated the facility should have notified the office as soon as the medication wasn't received so an alternative could have been given. Further, the MD indicated if an opioid medication was stopped abruptly severe withdrawal symptoms could occur as well as increased pain. During an interview on 11/1/24 at 12:34 p.m. the administrator stated the facility administration was made aware on Monday 10/14/24 of R23 not receiving the new pain medications. Further, verified the medications were not received and given in a timely manner when the facility didn't receive the ordered medications. During an interview on 11/1/24 at 1:33 p.m., nurse practitioner (NP) verified they did not complete a comprehensive assessment of R23's pain or withdrawal symptoms on 10/14/24. During review of the prescribing information on Belbuca.com on 10/31/24, revealed a warning: Serious and Life-threatening risks from use of Belbuca indicated serious, life-threatening, or fatal respiratory depression may occur with use of Belbuca, especially during initiation or following a dosage increase. To reduce the risk of respiratory depression, proper dosing, and titration of Belbuca are essential. The Highlights of Prescribing Information obtained from Belbuca.com website indicated not to abruptly discontinue Belbuca in patients who may be physically dependent on opioids. Rapid discontinuation of opioid analgesics in patients who are physically dependent on opioids has resulted in serious withdrawal symptoms, uncontrolled pain, and suicide. Rapid discontinuation has also been associated with attempts to find other sources of opioid analgesics, which may be confused with drug-seeking for abuse. Patients may also attempt to treat their pain or withdrawal symptoms with illicit opioids, such as heroin, and other substance. The Pain Management Protocol dated 3/23/23, indicated to ensure that residents with pain or at risk for pain, have an effective pain management plan in place with individualized interventions that are consistent with the resident's goals for comfort. Treatment/Management 1. With input from the resident and/or resident representative, the provider, and staff will establish goals of pain treatment, for example, freedom from pain with minimal medication side effects, less frequent headaches, or improved functioning, mood, and sleep. 2. Nursing will evaluate for appropriate non-pharmacologic interventions to address the individual's pain. 3. Provider will order appropriate medication interventions to address individuals' pain. 4. The staff will evaluate and report how much and how often the resident utilizes PRN pain medication. a. Depending on severity and location of pain, the provider may start with PRN doses or supplement routine doses with PRN doses for breakthrough pain. b. If there are more than occasional PRN analgesic utilization (and depending on the success of nonpharmacological interventions), the provider may consider changing to regular administration of at least one analgesic with another medication for PRN use, increasing the routine dose of an existing analgesic, or switching to another analgesic. 5. Staff will provide the elements of a comforting environment and appropriate physical and complementary interventions; for example, local heat or ice, repositioning, massage, and the opportunity to talk about chronic pain. 6. Resident's plan of care will reflect pain management needs. 7. For the individual who is receiving opioid analgesics, the provider may order a regimen of laxatives and other measures to prevent constipation. Monitoring 1. The staff will reassess the individual's pain and related consequences at regular intervals; monitoring will occur to ensure pain is controlled, care plan goals are met, and pain management regimen is effective. Review should include frequency and intensity of pain, ability to perform activities of daily living (ADLs), sleep pattern, mood, behavior, and participation in activities. 2. The staff will discuss significant changes in levels of comfort with the provider who will consider adjusting interventions accordingly. This may include non-pharmacological measures and adjustments of regular and PRN analgesic doses to find the best combination of effectiveness and tolerable side effects. 3. The staff and physician will monitor for adverse effects of pain medications such as gastrointestinal bleeding from nonsteroidal anti-inflammatory drugs (NSAIDs), and anorexia, confusion, lethargy, severe constipation, or ileus related to opioids.