[heron]

Not to insult anyone's intelligence, you might also double check the placement of the patch ... it needs subcutaneous fat to work properly and if the patch is placed over a bone (the sternum, for instance) or if the pt is emaciated and has no subcu. fat, it may not be working in the first place.
Unfortunately the pt and staff may be taking the flak for past practices of heavily medicating pts to "decrease" workload or as a "quick fix" in place of addressing the problem. In hospice we've seen many situations in which a pt's family gets terribly upset at staff who are "overmedicating" the pt. They've heard stories, known a friend of a friend, etc., etc. There is no easy solution to this ... attempts to educate may or may not work and, although reporting is an option, becoming adversarial right off the bat may make the situation worse by polarizing the discussion. My first move is usually what has been suggested above ... ask the dtr to sit with mom when pain is bad. Also, the post above is right in pointing out that, if the pt is legally competent, the POA has no authority. Sometimes, nothing works. I once had a pt with an exquisitely painful open wound that was constantly being soiled due to its location. The family was in serious conflict over pain medication and in serious denial abt the pt's condition ... the pt's wife was convinced that the morphine was killing her terminally ill husband. (Oversimplified, but that's the gist) One night, the family member who was sitting with the pt. called me to do wound care but refused to allow any medication whatsoever. I told her that to do so would be abuse and I refused. Shocked the dickens out of her, but we were eventually allowed to premedicate for wound care, at least.
One last note, I want to reinforce that documentation is key. If the pt is non-verbal or too confused to use the pain scale, document non-verbal signs ... grimacing, crying, elevated VS, restlessness or inconsolability. It'll give you data to use with further discussions with dtr or regulators. Good luck!