Health inspection·August 3, 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 clinical and administrative record review, and interview, the facility failed to provide evidence that adequate pain management was provided for 1 of 3 sampled residents reviewed for pain management, Resident # 5, as evidenced by failure to provide evidence of providing appopriate pain management when the patient voiced complaints of pain; failure to provide evidence of performing the appropriate pain assessment associated with the administration of pain medication and failure to accurately document the administration of pain medications. Residents Affected - Few The findings included: Review of the clinical record for Resident # 5 revealed the resident was admitted to the facility on [DATE] for Aftercare following joint replacement surgery. Review of the progress note dated 04/20/23 at 2:19 PM documented that staff report resident complained of left hip pain. The staff member followed up with the resident, who stated about 9:00 PM last night wanted to use bathroom and asked staff to help me with the left leg and since then my left hip is hurt like never before. The resident reported pain of 10 on scale 0-10. The physician was notified and a new order to send resident to the emergency room for evaluation. Review of the physician orders dated 04/19/23 documented the following pain medications were ordered: Percocet 5-325mg one tablet every 6 hours as needed for pain. Tramadol 50 mg one tablet every 6 hours for pain as needed. Tylenol 650 mg every 6 hours for pain as needed. Further review of the clinical record did not provide documentation that the resident was administered pain medication on 04/19/23 (Tylenol, Tramadol or Oxycodone). Review of the Medication Administration Record (MAR) showed that the first documented dose of pain medication (Tramadol) was administered on 04/20/23 at 5:30 AM, when the nurse administered Tramadol 50 mg. Further review of the MAR or record did not provide a pain assessment associated with the Tramadol administered. There was no documentation of a follow-up assessment for the administered dose of Tramadol. Additional review of the Medication Administration Record (MAR) documented the nurse had administered Percocet 5-325 mg at 04/20/23 at 12:56 PM. There is no documented pain assessment associated with the administration of the Percocet. There was no follow-up assessment to this pain medication for effectiveness. Page 1 of 2 105579 105579 08/03/2023 Savannas Park Health and Rehabilitation Center 1655 SE Walton Road Port Saint Lucie, FL 34952

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the Controlled Medication Utilization Record for Resident #5 documented that two (2) doses of Tramadol were removed on 04/20/23, one dose was documented 5:30 AM and one dose at 2:00 PM. The MAR documented the one administration (5:30 AM) and did not document the administration of the 2:00 PM dose of Tramadol. The Controlled Medication Utilization Record, reviewed for the Percocet, documented a dose was removed on 04/20/23 at 10:00 AM for the Oxycodone 5-325 mg (Percocet 5-325 mg). A telephone interview with Resident # 5 was conducted on 08/02/23 in the morning. The resident expressed that he was admitted to the facility in the afternoon and after he was transferred to the bathroom about 9:00 PM, he was in pain. He stated he told the nurse he was in pain and she told him that they could only give him Tylenol because they had to wait to receive the medication from pharmacy. He said the next day, he was still in pain and he wanted to go back to the hospital. An interview was conducted on 08/03/23 at approximately 3:00 PM with Staff A, the nurse who worked on 04/19/23 on the 3PM-11 PM and on 04/20/23 on the 11PM-7AM shifts. She stated she did not remember Resident # 5 specifically, but according to her review of the clinical record, she did her shift pain assessment and the resident had not complained of any pain. She stated she didn't recall if the resident complained of any pain later that evening. She stated that according to the record, she administered pain medication that morning to the resident after receiving the pain medication from the pharmacy. She stated that Pharmacy delivers medications between 4 and 5 AM, and if the medications are out for delivery, we can't get authorization for pain medication. The surveyor also inquired about what the resident's pain level was at the time the medication was administered on 04/20/23 at 5:00 AM. She stated she was not certain because the MAR was not indicating what the pain level was. She also confirmed that there is no documentation of a follow-up assessment to determine if the administered medication had been effective. 105579 Page 2 of 2