Health inspection·May 5, 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 Based on interview and record review, the facility failed to evaluate increased pain and provide pain relief for one of three sampled residents (Resident 1). Residents Affected - Few This failure resulted in Resident 1 experiencing unrelieved, moderate pain when standing and walking during rehabilitative care for one month and 5 days. Findings: A review of Resident 1's admission record indicated Resident 1 was admitted to the facility for pneumonitis (infection and inflammation of the lungs), abnormality of gait and mobility, and Parkinson's Disease (a disease resulting in loss of control of limbs and motor functions.) A review of Resident 1's Physical Therapy (PT) Assessment, dated 10/17/22, indicated Resident 1 received physical therapy five times a week which included standing and walking. During a phone interview on 2/23/23, at 2:47 p.m., with Resident 1, Resident 1 stated he did not get adequate pain relief for his left hip during his admission at the facility. Resident 1 stated he frequently rated his left hip pain a five or six on the pain scale (a verbal report of pain level, zero indicating no pain, one to three indicating mild pain, four to six indicating moderate pain and seven to ten indicating severe pain) and only received acetaminophen (a drug to relieve pain) for pain relief. Resident 1 stated he did not always get pain medication as requested, and the acetaminophen was not enough to relieve his hip pain. Resident 1 stated the pain was at its worst when standing and walking during physical therapy sessions. Resident 1 stated the facility frequently made him walk while he was in pain and did not provide him pain relief. During a concurrent interview and record review on 3/22/23, at 1:10 p.m., with Physical Therapy Aide (PTA), Resident 1's Physical Therapy Encounter note, dated 11/7/22, was reviewed. PTA stated the note indicated Resident 1 was unable to walk due to pain and there was a recommendation made to nursing to provide pain medication before physical therapy. During an interview and record review on 3/22/23, at 2:28 p.m., with Registered Nurse (RN 1), Resident 1's physician's order for acetaminophen, dated 10/18/22, Nursing Progress Note , dated 11/7/22, and Medication Administration Record (MAR), dated 11/2022, were reviewed. RN 1 stated Resident 1 had a physician's order for two tablets of acetaminophen to be given as needed for general discomfort and was not specifically ordered for Resident 1's hip pain. RN 1 stated the Nursing Progress Note indicated Resident 1 had left hip pain and could not complete physical therapy. Resident 1's progress note indicated Resident 1 be pre-medicated with pain medication before physical therapy. A review of Resident 1's MAR indicated Resident 1 did not receive acetaminophen on 11/7/22 but had received Page 1 of 2 056392 056392 05/05/2023 Pleasanton Nursing and Rehabilitation Center 300 Neal Street Pleasanton, CA 94566

F 0697 acetaminophen seven times in November 2022 for pain levels of five to six. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review, on 3/23/23, at 1:30 p.m., with physiatrist (PA, physical therapy specialist), Resident 1's physiatrist assessment, dated 12/12/22, was reviewed. The PA stated the assessment indicated Resident 1 reported frequent, unrelieved pain at his left hip for the past 24 hours and rated his pain at three (mild pain). The assessment indicated Resident 1 experienced increased pain with movement and physical exertion. Residents Affected - Few A review of Resident 1's MAR, dated 12/2022, indicated Resident 1 received did not receive acetaminophen on 12/11 or 12/12. During a phone interview on 3/23/23, at 2:15 p.m. with Resident 1's physician (MD), MD reviewed his progress notes for Resident 1. MD 1 stated he did not recall getting reports of Resident 1's left hip pain from staff and did not document Resident 1's report of pain until 12/7/22. A review of facility's policy and procedure (P&P), titled Pain - Clinical Protocol, dated 7/1/2020, indicated the nursing staff will identify any situations or interventions where an increase in the resident's pain may be anticipated. The P&P indicated staff will evaluate and report the resident/patient's use of standing and PRN (as needed) analgesics (pain medication). 056392 Page 2 of 2