Health inspection·December 12, 2023

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 manage two of three resident's (Resident 1 and Resident 2) pain according to professional standards of practice and resident's preferences when residents were not properly educated about their pain medication management. This failure resulted in increased pain levels and had the potential to cause a delay in recovery, impair mobility, impair mood, disturb sleep, and diminish quality of life and wellbeing. Residents Affected - Some Findings: During an interview on 10/31/23, at 3:03 p.m., Resident 1 stated she had pain on the lower back, neck, and her whole body. Resident 1 stated her scheduled pain medication was not given on time. The longest she had to wait was half hour, depending on the nurse on duty. Resident 1 stated she did not like to wait because it messed up her schedule and made her pain worse. Resident 1 stated, about two weeks ago, a night shift nurse refused to give her pain medication, because the previous nurse supposedly already gave her 11 p.m. pain medication. The night shift nurse told her she would give the medication at 3 a.m. but did not come back. Resident 1 stated she missed her 11 p.m., and 3 a.m. pain medication and finally received medication at 7a.m. Resident 1 stated she did not receive medication from the nurse who was supposed to give her pain medication at 11 p.m. Resident 1 stated her pain level was always 10 (numerical pain rating scale 0-10: where 0 is no pain and 10 is the worst pain imaginable), and it took twice as long to relieve the pain. The Nurse argued with her like she was crazy, or not stable, and did not know about her medication. Resident 1 stated she did not feel respected by that nurse. A review of Resident 1's admission Minimum Data Set (MDS - a federally mandated clinical assessment tool) dated 9/6/23 indicated she was admitted [DATE] with a Brief interview for Mental Status (BIMS – a tool to assess cognitive function) score of 13 indicating Resident 1 was cognitively intact. Resident 1's facesheet (resident demographics) indicated she was admitted with a diagnosis of cancer of the breast, pressure ulcer of the sacrum, diabetes, and depression among other medical conditions. A review of Resident 1's Medication Administration Record (MAR) for 9/23 and 10/23 indicated she was prescribed Morphine (narcotic pain medication) 30 milligram (mg - unit of measure equal to a thousandth of a gram) to be given one (1) tablet twice a day routinely and Oxycodone (another type of narcotic pain medication) 10 mg to be given one (1) tablet every four (4) hours as needed (PRN – to be administered when it is requested by, or as needed by, the patient; is not scheduled and not required on a regular basis) for moderate (level 4-6) and severe (level 7-10) pain. During a follow-up interview on 10/31/23, at 4:15 p.m., Resident 1 stated she expected the Page 1 of 2 055919 055919 12/12/2023 Apple Valley Post-Acute Rehab 1035 Gravenstein Hwy South Sebastopol, CA 95472

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Oxycodone every four hours. Resident 1 did not understand the order for the medication was to be administered every 4 hours PRN (as needed/ requested by the patient). During an interview on 10/31/23, at 3:33 p.m., Resident 2 stated she had back pain on the right side, had level 7 pain, and she had to wait at least 30 to 45 minutes for her pain medication. By that time the medication arrived she would be in tears. Resident 2 stated except for the two nurses who gave her medication on time, the others did not. Resident 2 states she did not feel respected, she felt like she was so much baggage. A review of Resident 2's admission MDS dated [DATE] indicated she was admitted [DATE] with a BIMS score of 14, suggesting she was cognitively intact. She had moderate level pain and was on pain medication. A review of Resident 2's Medication Administration Records for 10/23 indicated she was prescribed Oxycodone 5 mg to be given 1 tablet every 4 hours PRN for moderate (level 4-6) pain, and 2 tablets every 4 hours PRN for severe (level 7-10) pain. During a follow-up interview on 10/31/23, at 4:23 p.m., Resident 2 stated she thought the pain medication order was for Oxycodone every 6 hours. Resident 2 did not understand the order for her pain medication was to be administered every 4 hours PRN (as needed/per patients request). During a concurrent observation and interview on 10/31/23, at 4:28 p.m. Licensed Nurse A was observed administering 2 tablets of Oxycodone to a resident. Licensed Nurse A stated she had not asked the resident's pain level before she administered the medication. Licensed Nurse A stated she was told by her Certified Nursing Assistant that the patient was in pain. During an interview on 12/12/23, at 1:45 p.m., when asked who provides information to the residents about their pain medication, the Director of Nursing stated nurses explain the pain medication order and time of administration schedule to residents. Nurses educate patients about routine and PRN medication – it is a standard of practice. In cases when a medication is given early, [brand name ] -the computer program used by the facility for medication administration-, gave nurses a warning of an early administration of medication, but they could administer as early as an hour before schedule, then the nurse would have to complete a supplemental documentation of the early medication administration. During an interview on 12/13/23, at 11:17 a.m., Licensed Nurse B was asked what information was provided to a resident about their pain medication. Licensed Nurse B stated, depending on the physician order, a routine medication the resident did not have to ask for, it was [NAME] to them; it was usually ordered for consistent pain. A PRN (as needed) medication, the resident had to ask for, and the nurses would assesses pain if controlled or not. It was a nurse's duty to assess pain. Routine medication education included how early the medication may be given. When asked when this information was provided to the resident, Licensed Nurse B stated, every day or every time the resident verbalized misunderstanding. When asked why information on medication was not provided to a resident, Licensed Nurse B stated, some nurses did not know their patient well – they had not observed when (pattern or time) the patient took their medication, had not assessed the effectiveness of the pain medication, were lazy, or had not reviewed the patient's medication order. 055919 Page 2 of 2