Other·March 23, 2021

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 ensure staff followed its policies to provide pain management for two of twelve sampled residents (Resident 76 and Resident 77). This failure resulted in 1) Resident 76 suffering from intolerable pain, up to a level 10, on a pain scale from 0 to 10 (0 being no pain, 10 being the worst pain experienced in one's lifetime) and crying for two weeks from back pain and not being able to sleep at night, and 2) Resident 77 suffering from severe pain, up to a level 9, on a pain scale from 0 to 10 for four days from a left femur (Thigh bone) fracture, which made her unable to participate in physical therapy, and become depressed. 1) Resident 76 Resident 76 was admitted to the facility on 09/29/19 with medical diagnoses including Low Back Pain, Neuralgia (Intense, typically intermittent pain along the course of a nerve) and Pain in Thoracic Spine (Pain caused by joint dysfunction where the ribs attach to the spine), according to the facility Face Sheet (Facility demographic). Resident 76's MDS (Minimum Data Set-An assessment tool) dated 9/30/19 indicated her BIMS (Brief Interview for Mental Status-a structured evaluation aimed at evaluating aspects of cognition in residents in Medicare or Medicaid certified nursing homes) score was 14, which indicated her cognition was intact. Resident 76's MDS also indicated she required assistance with bed mobility and transfers. During an interview on 10/08/19 at 10:56 a.m., Resident 76 stated that for the last two weeks, the facility had not been able to obtain her pain medication, therefore, she had to call her husband to bring her pain medication from home. Resident 76 explained she had undergone several back surgeries that caused her intolerable pain, and she needed Oxycodone (A narcotic pain medication used to treat moderate to severe pain) 30 mg tablets to keep her pain under control. Resident 76 stated her pain level was a 10 on a scale from 0 to 10 during the interview and was observed crying. A Nursing Note for Resident 76 dated 09/30/19 at 2:01 p.m., indicated, "Pt (Patient) c/o (complains) 10/10 pain. pain not controlled by current meds." A Nursing Note dated 10/08/19 at 1:00 p.m. indicated, "PT (patient) continues to state pain 10/10." During a second interview on 10/09/19 at 8:57 a.m., Resident 76 stated Oxycodone 30 mg was the medication prescribed by her "pain medication doctor" to control her pain, and it was effective if administered as prescribed, every four hours. She stated she was told by facility staff that the facility contracted pharmacy had to drive her pain medication from Bakersfield, and as a result it took a long time to get it. Resident 76 also stated her pain level was greater than a 10, on a scale from 0 to 10, enough to where she thought she was going to throw up. Resident 76 stated her husband was bringing Oxycodone 30 mg tabs to the facility in a plastic zip lock bag, for medication administration by Licensed Staff. She stated she told "everybody" at the facility about her pain issues. Resident 76 stated her pain was so bad she could not sleep at night, and the facility would not give her anything to sleep. A Physician's Order, dated 09/29/19 at 6:20 p.m., indicated, "oxycodone HCI Tablet 30 MG Give 30 mg by mouth every 4 hours as needed for PAIN MANAGEMENT." During a phone interview on 10/09/19 at 9:40 a.m., Resident 76's husband confirmed he brought Oxycodone 30 mg tablets from home for Resident 76's pain management at the facility. He stated he brought five tablets on three different occasions (for a total of 15 tablets) and gave them to Licensed Nurses at the facility. Resident 76's husband stated nothing was returned to him so he assumed Licensed Nurses used all the Oxycodone tablets he brought to the facility. During an interview on 10/09/19 at 2:07 p.m., the Director of Nursing (DON) stated Oxycodone 30 mg tablets were not in the facility's emergency kit during Resident 76's admission, and it had taken the facility contracted pharmacy longer than four hours for delivery. Other medications were administered to Resident 76 to control the pain but were ineffective. During an interview on 10/10/19 at 1:02 p.m., Licensed Nurse P, Resident 76's assigned nurse, confirmed administering Oxycodone 30 mg tablets brought to Resident 76 from home. Licensed Nurse P stated the medication came in a bottle labeled with the resident's name, description and dose. Licensed Nurse P stated she called the facility contracted pharmacy by phone to verify the medication brought from family was indeed Oxycodone 30 mg tablets. Licensed Nurse P stated after receiving verification from pharmacy, based on the description of the tablet, and obtaining a physician's order, she administered the medication Oxycodone 30 mg tablets to Resident 76. During an interview on 10/11/19 at 11:54 a.m., Licensed Nurse E confirmed Resident 76's husband brought three Oxycodone 30 mg tablets in a zip lock bag on 9/30/19, completely unlabeled, for administration. Licensed Nurse E stated she was the staff member who accepted the tablets, and had the husband sign a document indicating the type and dosage of medication brought from home for accountability purposes. She disproved Licensed Nurse P's statement on 10/10/19 at 1:02 p.m. that the Oxycodone 30 mg tablets from home came in a labeled bottle. Licensed Nurse E stated it usually took six hours for pharmacy to deliver pain medication not available at the facility. A facility document titled, "Controlled Substance Accountability Sheet," dated 09/30/19, indicated Resident 76's husband brought three tablets of Oxycodone 30 mg to the facility, and they were accepted by Licensed Nurse E. A medication dispensing record provided by the DON on 10/16/19 at 9:45 a.m. indicated pharmacy delivered only two tablets of Oxycodone 30 mg to the facility on 10/02/19. Resident 76's Medication Administration Record indicated these two 30 mg tabs of Oxycodone were administered to Resident 76 that same day (on 10/02/19), leaving her out of her prescribed medication again. According to the medication dispensing record, the pharmacy did not deliver more Oxycodone 30 mg tablets until 10/08/19 (six days later). For 6 days, Resident 76 received only two oxycodone 30 mg tabs from the facility contracted pharmacy, and fourteen tablets from other sources, presumably from medication brought from home. Resident 76's Medication Administration Record indicated Resident 76's pain level was an 8 out of 10 on 10/03/19, 10/04/19, 10/06/19 and 10/08/19. Resident 76's pain level was a 10/10 on 10/07/19. During an interview on 10/14/19 at 12:05 p.m., the DON stated medications that came in a zip lock bag, unlabeled, from home, were not acceptable for facility administration. During an interview on 10/11/19 at 9:42 a.m., Resident 76 stated she had been crying at the facility as a result of having a pain level of 10 out of 10. She stated it took a couple days to get her pain under control, but it had finally been managed. She confirmed her husband brought the Oxycodone 30 mg tablets from home in an unlabeled clear plastic zip lock bag, and they were accepted by the facility for administration. Resident 76 stated she was in "misery" (A cause of great distress or discomfort) for two weeks, often crying in pain. When asked if she had suffered as a result of this issue, Resident 76 stated, "More than suffering." Resident 77 Resident 77 was admitted to the facility on 10/07/19 with medical diagnoses including Fracture of Lower End of Femur (Thigh bone) and Neuralgia, according to the facility Face Sheet. Resident 77's pain level had been documented as an 8 out of 10 on 10/07/19 and 10/08/19, in her Medication Administration Record. During an interview on 10/08/19 at 2:47 p.m., Resident 77 stated her pain level was a 9, on a scale from 0 to 10. She stated her pain level had not been controlled since admission, and the morning of 10/08/19 she was unable to do her physical therapy as a result of the intolerable pain. Resident 77 stated she had pain from a fracture to her left femur (thigh bone). Resident 77 stated staff informed her that facility physicians would not prescribe medication for her, and she had not seen a physician herself. During an interview on 10/08/19 at 4:43 p.m., Licensed Nurse P, nurse assigned to Resident 77, stated she called the physician that morning (10/08/19) to notify him that Resident 77's pain was not in control, and to request pain medication. The physician gave an order for Norco (Hydrocodone-Acetaminophen-A narcotic analgesic used to treat moderate to severe pain). Licensed Nurse P stated she immediately faxed and called pharmacy at 10:18 a.m., to obtain permission from pharmacy to withdraw the narcotic from the facility's emergency kit. Licensed Nurse P stated that in order to obtain a controlled medication from the emergency kit, pharmacy authorization was required. Licensed Nurse P explained that by 2:00 p.m. she had not received authorization from pharmacy to withdraw the medication from the emergency kit, therefore, she called back to follow up. Licensed Nurse P stated pharmacy put her on hold, and when she finally spoke to a pharmacy representative, was told they had just received her request in regards to Resident 77's Norco order. Licensed Nurse P stated she did not get approval from pharmacy until approximately 3:00 p.m. A Physician's Order dated 10/08/19 at 10:18 a.m., indicated, "Norco Tablet 5-325 MG (HYDROcodone-Acetaminophen) Give 1 tablet by mouth every 4 hours as needed for prn (as needed) pain." During a phone interview on 10/08/19 at 5:01 p.m., Pharmacy Technician U, employed by the facility contracted pharmacy, confirmed receiving a request for Norco the morning of 10/08/19, for Resident 77. She stated pharmacy, "Got behind," and she did not know why the medication's withdrawal from the emergency kit was not approved earlier for facility use. Resident 77's Medication Administration Record indicated Norco (Hydromorphone-Acetaminophen) 5-325 mg, was administered for the first time to Resident 77 on 10/08/19 at 3:36 p.m., more than six hours after it was ordered by the physician. During an interview on 10/09/19 at 2:09 p.m., the DON confirmed Resident 77 had a new prescription for pain medication because her pain was not being controlled. The DON stated she had to call the pharmacy's general manager on 10/08/19 at around 3:00 p.m. to get the pharmacy's approval to obtain the medication from the emergency kit. Resident 77's Nursing Plan of Care for pain, initiated on 10/07/19, did not list specific pharmacological or non-pharmacological interventions to help alleviate or manage Resident' 77's pain. The care plan was not resident centered and had standardized pain interventions, including, "Identify, record and treat resident's existing conditions which may increase pain and discomfort ...Monitor/document for probable cause of each pain episode. Remove/limit causes where possible." During an interview on 10/11/19 at 9:34 a.m., Resident 77 stated she suffered in horrible pain for several days and was starting to get depressed. During an interview on 10/14/19 at 12:30 p.m., the DON stated they were having issues with pharmacy. She stated pharmacy was not sending them controlled pain medications in a timely manner and made them wait on the phone a long time to speak to a representative. She also stated when pharmacy had to send medications out of stock at the facility, it took pharmacy four hours to deliver it, unless it was sent by satellite, in which case the medication was delivered a bit faster. The DON stated the facility's administrator knew about this issue. The facility policy titled, "PROVIDER PHARMACY REQUIREMENTS," last revised in August of 2014, indicated, "The provider pharmacy agrees to perform the following pharmaceutical services, including but not limited to: 7) Providing routine and timely pharmacy service as contracted and emergency pharmacy service 24 hours per day, seven days per week." The facility policy titled, "Recognition and Management of Pain," last revised in July of 2017 indicated, "It is the policy of this facility to 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 resident's goals and preferences." The facility policy titled, "Pain Management," last revised in July of 2019, indicated, "it is the policy of this facility that pain management is achieved through individualized recognition, assessment, treatments and monitoring of resident's needs through an interdisciplinary and holistic approach." The facility failed to ensure staff followed its policies to provide pain management for two of twelve sampled residents (Resident 76 and Resident 77). This failure resulted in 1) Resident 76 suffering from intolerable pain, up to a level 10, on a pain scale from 0 to 10 (0 being no pain, 10 being the worst pain experienced in one's lifetime) and crying for two weeks from back pain and not being able to sleep at night, and 2) Resident 77 suffering from severe pain, up to a level 9, on a pain scale from 0 to 10 for four days from a left femur (Thigh bone) fracture, which made her unable to participate in physical therapy, and become depressed. This violation had a direct or immediate relationship to the health, safety, or security of residents.