Health inspection·December 12, 2024

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice related to pain management for one of four sampled residents (Resident 1) when Resident 1 did not receive the right dosage of oxycodone (a controlled drug used to treat moderate to severe pain) to manage severe pain to right hip. This failure had the potential to affect Resident 1's well-being. Residents Affected - Few Findings: Review of Resident 1's clinical record titled, admission Record, indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including displaced subtrochanteric fracture of right femur (a severe injury to the thigh bone where the fractured ends is out of alignment), aftercare following joint replacement surgery (a procedure in which a surgeon removes a damaged joint and replaces it with new, artificial part), polyneuropathy (multiple nerve damage), presence of right artificial hip, and need assistance with personal care. Review of Resident 1's 5-day minimum data set (MDS, federally mandated resident assessment tool) assessment dated [DATE], indicated Resident 1's brief interview for mental status (BIMS, a tool used to assess cognition [knowing, learning, and understanding things]) score was 13 (0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact). Further review revealed, Resident 1 had frequently experienced pain, and frequently limited her participation in rehabilitation therapy (a form of treatment to restore function to those recovering from an injury or surgery) sessions, and day to day activities because of pain over the last 5 days. Review of Resident 1's clinical record titled, Order Summary Report, indicated an order of oxycodone hydrochloride (HCl)10 milligrams (mg, unit of measurement) every 6 hours as needed for moderate to severe pain which was ordered on 11/30/2024. Review of Resident 1's list of care plan titled, The resident had pain ., date initiated 12/2/2024, indicated, Anticipate the resident's needs for pain relief and respond immediately to any complaint of pain .Monitor Pain every shift and PRN [pro re nata - as the need arises] when giving PRN meds [medications] (0= no pain, 1-3= mild pain, 4-6= moderate pain, 7-10= severe pain). Review of Resident 1's December medication administration record (MAR, a record of medications given), indicated an order of oxycodone HCl 5 mg started on 11/30/2024, to be given every 6 hours as needed for moderate pain (4-6 pain scale). Further review indicated on 12/1/2024 at 2:36 a.m., Resident 1 had pain scale of 8 (severe pain) and on 12/2/2024 at 6:00 a.m., Resident 1 had pain scale of 7 (severe pain). Resident 1 was given 5 mg of oxycodone HCl on both times which was indicated for Page 1 of 2 055462 055462 12/12/2024 Hazel Hawkins Memorial Hospital D/P Snf 911 Sunset Drive Hollister, CA 95023

F 0697 moderate pain. Level of Harm - Minimal harm or potential for actual harm During a phone interview with Resident 1's family member on 12/12/2024 at 8:43 a.m., Resident 1's family member stated their complaint was about how the facility managed Resident 1's pain. Resident 1's family member further stated, their mother was supposed to get 10 mg of oxycodone every 6 hours but Resident 1 was given 5 mg instead. Resident 1's family member confirmed Resident 1 had dislocated her right hip which made her experienced severe right hip pain. Residents Affected - Few During a concurrent interview with registered nurse A (RN A) and record review on 12/12/2024 at 2:00 p.m., RN A reviewed Resident 1's December MAR. RN A confirmed Resident 1 had severe pain on 12/1 at 2:36 a.m. and on 12/2 at 6:00 a.m. and was only given 5 mg of oxycodone HCl. RN A further confirmed the 5 mg of oxycodone HCl should only be given for complained of moderate pain which was 4-6 in pain scale. RN A stated the order for the use of 10 mg of oxycodone HCl should have been clarified because the given parameter for moderate to severe pain had caused confusion. During a concurrent interview with registered nurse B (RN B) and record review on 12/12/2024 at 2:26 p.m., RN B reviewed Resident 1's December MAR. RN B confirmed Resident 1 should have been given 10 mg of oxycodone HCl for pain scale of 8 and 7. During a phone interview with registered nurse C (RN C) on 12/12/2024 at 2:44 p.m., RN C confirmed she was one of Resident 1's nurses. RN C stated the pain scale of 7-10 was an indication of severe pain and oxycodone HCl 10 mg was ordered for severe pain. During a concurrent interview with interim director of nursing (IDON) and record review on 12/12/2024 at 2:52 p.m., IDON reviewed Resident 1's December MAR. IDON confirmed on 12/1 at 2:36 a.m. and on 12/2 at 6:00 a.m., Resident 1 had severe pain and should have been given oxycodone HCl 10 mg. During a review of the facility's policy and procedure titled, Pain Management, dated 11/05, indicated, .pain also will be assessed at minimum of every shift, and as needed. Pain will be documented on pain MAR. 3. Licensed nurse will assess pain and document the pain level on the supplemental documentation of MAR when any PRN pain medication was given. 055462 Page 2 of 2