Health inspection·February 22, 2022

§483.25(k) Pain Management The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. The facility failed to care plan, reassess, manage, and carry out physician orders for one of three sampled residents (Resident 1), to prevent high levels of pain. As a result, Resident 1 suffered pain levels of 5-10/10 (The numerical pain scale is a tool to help assess a resident's pain, where a level of 0/10 means no pain, 5/10 is moderate pain, and 10/10 is the worst possible pain) at the facility, for 21 days in March of 2019. Record review revealed Resident 1 was admitted to the facility on 2/28/19, with medical diagnoses including Atrial Fibrillation (Irregular heart rhythm), Weakness, Need for Assistance with Personal Care, Abnormalities of Gait and Mobility, Anemia (Low number, or dysfunctional red blood cells that can lead to reduced oxygen flow to the body's organs), Chronic Kidney Disease, Peripheral Vascular Disease (A circulatory problem in which narrowed arteries reduce blood flow to the limbs), COPD (Chronic obstructive pulmonary disease- A group of diseases that cause airflow blockage and breathing-related problems) and Obesity, according to the facility Face Sheet (Facility demographic). The Face Sheet indicated Resident 1 had a prior admission to the facility in 2014. Record review revealed Resident 1's Physician Progress Notes dated 3/05/19, written by Physician G, which indicated Resident 1 had left knee pain and right shoulder pain. These notes also indicated Resident 1 suffered from Peripheral Neuropathy (The result of damage to one or more groups of nerves). During an interview on 10/01/21 at 9:30 a.m., the Director of Nursing (DON) stated Physician G no longer worked for the facility. Record review revealed Resident 1's MAR (Medication Administration Record) for March of 2019, indicated Resident 1 had pain levels of 5/10 or above, on the following days: 3/03/19, 3/04/19, 3/05/19, 3/06/19, 3/07/19, 3/10/19, 3/12/19, 3/14/19, 3/15/19, 3/16/19, 3/17/19, 3/18/19, 3/20/19, 3/21/19, 3/27/19, 3/28/19, 3/29/19 and 3/30/19. On 3/06/19, 3/12/19, and 3/18/19, Resident 1's pain level was documented as 10/10. The MAR did not indicate the pain location, duration, intensity, or character. During an interview on 10/01/21 at 10:53 a.m., Physical Therapist D, who remembered Resident 1, stated Resident 1's physical therapist sessions were conducted at 3 p.m., during her 2019, admission. Record review revealed Physician orders dated 2/28/19, which indicated, "Tylenol Tablet 325 MG (Milligrams) (Medication to relieve pain) Give 2 tablet by mouth two times a day for pain. Give prior to therapy and QHS (Every bedtime)." While in the original physician orders, no specific time was documented for administration, in the Medication Administration Record (MAR), this medication was scheduled at 8 a.m. and 8 p.m., and documented as administered daily at these times. By the time Resident 1 had physical therapy, it had been seven hours since she had received Tylenol for pain, according to the documentation. Record review revealed Physician orders dated 2/28/19, which indicated, "Tylenol Tablet 325 MG (Milligrams) Give 1 tablet by mouth every 12 hours as needed for Pain." There was no documentation this medication was administered on an as-needed basis, throughout the month of March 2019, despite Resident 1's documented high pain levels. The Administrator was asked to provide all nursing care plans on pain, on 8/17/21 at 12 p.m. The care plans on pain provided by the Administrator during an e-mail on 8/19/21 at 1:14 p.m., had been initiated in 2014, and were not active in March of 2019. During an interview with the DON on 10/01/21 at 12:45 p.m., she stated, up to the present time, the facility did not reassess pain levels after the administration of Acetaminophen (A medication used to relieve pain). After review of Resident 1's MAR for 2019, the DON stated there was no way to know if Acetaminophen was effective in relieving Resident 1's pain. The DON stated, when Licensed Nurses identified high pain levels in residents, they were required to administer a PRN (As necessary) pain medication, reassess for effectiveness of the medication, and if the pain was not relieved, notify the physician. The DON stated all these steps needed to be documented. During a second interview with the DON on 10/01/21 at 1:30 p.m., she stated she was unable to find an active care plan for pain during Resident 1's admission in 2019. The DON also stated she was unable to find any pain reassessments for Resident 1, during March of 2019. During a phone interview with Family Member BB, on 9/15/21 at 8:51 a.m., he stated he felt Resident 1's pain at the facility was not managed or controlled, as she showed obvious signs of pain through facial expressions, in addition to verbally complaining of pain, including during her physical therapy sessions. The facility policy titled, "PAIN MANAGEMENT," last revised in November of 2017, indicated, "This facility recognizes a patient's right to be free of pain and promotes pain relief through the use of the Pain Management Plan during the patient duration of stay at a facility to help the patient attain or maintain his or her highest practicable level of well-being and to prevent or manage pain to the extent possible ...The licensed nurse communicates the adequacy of pain management and/or changes in pain significance to the physician at admission and as needed based on assessment and reassessment date throughout the patient stay ...Pain is assessed at least every shift, when a patient complains of pain and after an analgesic (Medication used to relieve pain) is given to determine effectiveness of the analgesic ...When pain is identified, assessment and documentation includes pain scale rating, location, duration, intensity and character ...A plan of care is developed for patients, documented and updated as needed." Therefore, the facility failed to care plan, reassess, manage, and carry out physician orders for Resident 1, to prevent high levels of pain. As a result, Resident 1 suffered pain levels of 5-10/10, at the facility, for 21 days in March of 2019. This violation had a direct or immediate relationship to the health, safety, or security of Resident 1.