Health inspection·April 14, 2025

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 ensure a pain medication (med/s) was available for one of three sampled residents reviewed for pain management (Resident 1). Residents Affected - Few This failure had the potential to cause the resident unnecessary pain, negatively affecting the resident's quality of life. Findings: Resident 1 was readmitted to the facility on [DATE] with diagnoses which included chronic ulcer (sore) of the left foot and gout (a type of inflammatory arthritis that causes pain and swelling in your joints), per the facility's admission Record. A record review was conducted of Resident 1. Resident 1's History and Physical (H & P), dated [DATE], indicated the attending physician (AP) documented Resident 1 had the capacity to make own decisions. A record review was conducted of Resident 1. Resident 1's minimum data set (MDS - a federally mandated resident assessment tool), dated [DATE], indicated Resident 1's brief interview for mental status (BIMS, ability to recall) score was 15/15 (a score of 13 to 15 suggests the patient is cognitively [process of acquiring knowledge and understanding] intact). A review of Resident 1's care plan for pain, dated [DATE], indicated, .Advise resident to request pain medication before pain becomes severe .Medicate resident as ordered for pain . On [DATE] at 2:51 P.M., an observation and an interview with Resident 1 was conducted in his room. Resident 1 was sitting by his bed, with right below the knee amputation (surgical removal of limb) and a gauze bandage was wrapped in his left foot. Resident 1 stated he runs out of pain medication. Resident 1 stated he asked for it and he was told the prescription for his pain medication had expired and needed a renewal of prescription from the physician. Resident 1 stated he was in pain and did not have a good night sleep for the last three to four days because of pain. Resident 1 stated, They should be ordering before I ran out, they should be doing that prior to last day. I have blisters and it hurts, they put me to that misery. On [DATE] at 4:18 P.M., an interview was conducted with Certified Nursing Assistant (CNA) 4. CNA 4 stated she worked with Resident 1 couple of days in a week. CNA 4 stated Resident 1 was nice, alert, oriented and knew what was going on. CNA 4 stated the only time Resident 1 called was when he needed his dressings change of his left foot and needed pain medication. Page 1 of 2 055954 055954 04/14/2025 National City Post Acute 220 East 24th Street National City, CA 91950

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On [DATE] at 4:38 P.M., a joint review of Resident 1's clinical record and an interview was conducted with Licensed Nurse (LN) 1. LN 1 stated she was familiar with Resident 1. LN 1 stated Resident 1 has a as needed pain meds and that Resident 1 was, usually has pain . LN 1 stated Resident 1 had pain medications ordered as needed, and Resident 1 gets it like every day. LN 1 stated during her (LN 1) shift on [DATE], Resident 1 complained of pain of his left foot. LN 1 stated there was no pain medication for Resident 1. LN 1 stated there was no documentation Resident 1 received pain medication on 4/10 through [DATE]. Per LN 1, Resident 1 complained he (Resident 1) was really in pain during the past few days he did not receive his pain medication. LN 1 stated she did not see any renewal or authorization form sent to the attending physician for pain med prescription renewal. On [DATE] at 3:10 P.M., a telephone interview was conducted with LN 2. LN 2 stated she worked with Resident 1 on [DATE]. LN 2 stated Resident 1 requested pain meds during her (LN 2) shift. LN 2 stated there was no pain meds for Resident 1 since the LNs in the morning shift used the emergency meds from the emergency cart. LN 2 stated, the following day, [DATE], Resident 1 requested pain meds during her (LN 2) shift. Per LN 2, there was no pain meds for Resident 1. Per LN 2 she (LN 2) explained to Resident 1 the reason he (Resident 1) did not get his pain meds. LN 2 stated, It was the weekend so even we followed it up, the doctor cannot sign it. LN 2 stated she knew about Resident 1's left foot. LN 2 stated the process was in the med pack, the pack had a color code meaning a level when to place a med order for the resident. LN 2 stated when that level hit, We have to call the doctor before the weekend hits to make sure the residents get their medications. On [DATE] at 3:27 P.M., a telephone interview was conducted with the Director of Nursing (DON). The DON stated the expectation was to make sure pain medications were available for the residents for pain management and prevent their sufferings. A review of the facility's policy titled, Pain Management, dated [DATE], indicated, Purpose: To maintain the highest possible level of comfort for residents by providing a system to .treat, and evaluate pain . 055954 Page 2 of 2