Resident #148 fell on September 24, 2025. He would not receive any pain medication until 3:40 p.m. the following day.
The night shift certified nursing assistant heard the resident scream when staff changed him early in the shift on September 24. CNA #211 told inspectors she believed the screaming was "because he was stiff." When the resident screamed, the nurse came to see what was wrong because his room sat directly across from the nurse's station.
The CNA changed the resident again later that night. She could not remember if he yelled out the second time.
The night nurse documented no pain assessments during her shift. She recorded no pain interventions, no medication offers, and no medication refusals. The nurse confirmed to inspectors that she never contacted hospice about the resident's condition during the night.
By morning, nursing staff documented that Resident #148 was experiencing pain. A nursing progress note on September 25 at 6:44 a.m. recorded his pain following the fall. A hospice note at 11:16 a.m. that same day also documented his pain.
The Director of Nursing verified the resident had pain after the September 24 fall. She confirmed that facility records showed no documented offers or refusals of pain medication, no attempts by staff to obtain pain medication, and no pain medication provided until September 25 at 3:40 p.m.
The DON told inspectors she recalled seeing the resident's swollen ankle. She denied remembering whether the resident was acting like he was in pain.
Two other nursing assistants worked while Resident #148 was at the facility during this period. CNA #212 failed to return the inspector's phone call. CNA #213 no longer worked at the facility and had no working telephone number.
The facility's pain assessment and management policy, dated 2001, required staff to assess residents for pain at admission and during ongoing assessments. The policy mandated monitoring residents for pain and determining the need for further assessment when there was a change of condition.
Inspectors found the facility failed to follow its own pain management protocols for nearly a full day while a hospice patient experienced documented pain and distress.
Federal inspectors classified the violation as causing actual harm to residents. The investigation stemmed from a complaint filed against the facility.
The case illustrates gaps in pain management for vulnerable residents during overnight shifts when fewer supervisory staff are present. Resident #148's room location directly across from the nurse's station meant his screaming was clearly audible to medical staff.
Hospice patients typically receive specialized pain management protocols given their terminal diagnoses and comfort-focused care goals. The 19-hour delay in pain medication represented a significant departure from standard hospice care practices.
The facility's 2001 pain management policy had remained unchanged for over two decades, potentially indicating outdated protocols for assessing and treating resident pain.
Night shift documentation revealed systematic failures in pain assessment and intervention. The nurse's failure to contact hospice services during the resident's distress violated coordination protocols for hospice patients requiring around-the-clock comfort measures.
Staff interviews revealed conflicting recollections about the resident's condition and pain levels. While the CNA attributed the screaming to stiffness, medical documentation the following day confirmed actual pain requiring intervention.
The swollen ankle observed by the Director of Nursing suggested possible injury from the fall that went unaddressed during the overnight hours. The DON's inability to recall whether the resident appeared to be in pain raised questions about staff training in pain recognition and assessment.
Federal regulations require nursing homes to ensure residents receive appropriate pain management, particularly those in hospice care focused on comfort rather than curative treatment. The facility's failure to provide timely pain relief violated these requirements.
The case demonstrates how communication breakdowns between nursing staff and hospice providers can leave terminal patients without adequate comfort measures during critical periods of distress.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Willoughby Post Acute from 2025-10-22 including all violations, facility responses, and corrective action plans.