Other·January 13, 2021

F726 Competent Nursing Staff CFR(s): 483.35(a)(3)(4)(c) §483.35 Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e). §483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. §483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs. §483.35(c) Proficiency of nurse aides. The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. The facility failed to ensure that five of five Licensed Nurses (LN) recognized and addressed a change of condition, when Resident 1 complained of pain 9/10 (Pain Level 7-10=Severe Pain; disabling; unable to perform ADLs) in her left knee; and two nurses failed to administer pain medication as ordered by Primary Care Physician (PCP) A, when it was given every four hours, but was ordered every eight hours. Licensed Nurse (LN) D, E, F, G, and H, all became aware of Resident 1's high level pain complaint 9/10 reported on 06/07/19 at 9:00 a.m. None of the five LNs called PCP A to report it. Five nurses did not follow the facility policy for reporting change of condition, did not follow their job description, and did not practice according to professional standards. These failures caused Resident 1 to suffer with severe pain and crying, restricted movement, swelling, and discoloration of her left knee while staff continued to manipulate the left knee (with turning, positioning Resident 1 onto a bedpan, and moving her in or out of bed). PCP A did not initiate an assessment or intervention until 72 hours after Resident 1's initial complaint, during PCP A's regular rounds on Monday 06/10/19. It was four days from date of complaint 06/07/19 to date of X-ray report confirming a fracture of the left knee on 06/11/19. On 06/13/19, an unannounced visit was conducted at the facility to investigate a facility reported incident regarding resident injury of unknown origin. During a record review from a local hospital, of Resident 1's "Discharge Summary", dated 04/05/19 for service dates of 03/14/19 to 03/18/19 indicated: "...Primary Discharge Diagnosis: Acute bilateral lower extremity (both lower legs) weakness, likely secondary to medication...Urinary Tract Infection,...History of dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning)...came in with weakness to the emergency room, unable to pick her legs up. The patient had weakness..." There was no diagnosis indicating Resident 1 had Chronic Knee Pain in the discharge Summary. During an interview on 06/13/19, at 3:50 p.m., Nurse Manager B was asked what happened to Resident 1, she stated that Resident 1 had a history of knee pain. Nurse Manager B stated Resident 1 complained of left knee pain 9/10 (Pain Level 7-10=Severe Pain; disabling; unable to perform ADLs) on the morning of 06/7/19. Resident 1 received two doses of pain medication at 9:00 a.m., and 1:30 p.m. During the evening shift at 9:00 p.m., Resident 1 complained of pain again and swelling of the knee was noted. Nurse Manager B stated Resident 1 received pain medication, Family 2 and PCP A were called. During a record review on 06/13/19 for Resident 1, the "Radiology Report," dated 06/10/19 (x-ray taken) with Radiologist signature of 06/11/19 (radiologist read it), indicated: "...Results: There is a fracture involving left lateral tibial plateau with no displacement...(A tibial plateau fracture is a break of the upper part of the tibia (shinbone) that involves the knee joint. Symptoms include pain, swelling, and a decreased ability to move the knee)...Conclusion: Tibial plateau left knee fracture as described above. Fracture of the knee. The age is unclear and should be correlated with site of pain and timing of injury. During an observation and interview on 06/13/19, at 4:16 p.m., Resident 1 was sitting up in her lounge chair with her legs up. Resident 1 was alert and oriented with a very soft voice. Resident 1 required time to process the question before answering it, usually about 10 to 15 seconds. When asked what happened, Resident 1 stated that it was on Tuesday about 2 a.m. when her knee began to hurt. It was painful when she hit the blanket while turning. Resident 1 stated the CNA (Certified Nursing Assistant) did not stop when she complained of pain. When asked if she remembered the name of the CNA, Resident 1 did not remember. When asked if she told anyone, Resident 1 stated "No, they were around." When Resident 1 was asked, what she meant, she did not respond. During an interview on 06/13/19, at 4:20 p.m., LN E stated that on 06/06/19, the last day she worked before the incident, Resident 1 was comfortable, alert, oriented, a 1-person assist (needing guidance due to her poor vision) to get up out of bed or transfer from bed to chair using the transfer pole in her room. LN E stated that on 06/08/19, day shift staff endorsed to her that Resident 1 complained of soreness with touching, and was getting pain medication every shift. During an interview on 06/13/19, at 4:40 p.m., Certified Nursing Assistant (CNA) K stated Resident 1 could turn herself and was a 1-person assist before she complained of pain at 9/10 in her left knee. CNA K stated after the complaint was made of 9/10 in her left knee, she became a 2-person assist for transfers, and could not bear weight on the left leg. During an observation on 06/13/19, at 5:20 p.m., Resident 1's left leg, the outer aspect of it, was severely bruised with discoloration of black, purple, and blue. The discoloration extended on the outer aspect of the left knee about four inches above the knee joint, and six inches below the knee joint. Resident 1 did have some discomfort noted by facial grimace during observation when staff manipulated her left knee for observation. During an interview on 06/24/19, at 11:45 a.m., CNA I stated she worked on 06/06/19, and on 06/07/19 the day before and the day of the incident with Resident 1's complaint of pain 9/10 in her left knee. CNA I stated that Resident 1 was a 1-person assist, but after the complaint was a 2-person assist and needed the Hoyer lift (a mechanical device used to lift residents who were non-ambulatory) to transfer Resident 1 from bed to chair or chair to bed. CNA I stated that Resident 1 was "in a lot of pain" with any movement and could not extend her left leg without pain. During an interview on 06/24/19, at 10:20 a.m., PCP (Primary Care Physician) A was on rounds, but had not seen Resident 1 yet. PCP A stated he was informed during rounds on Monday, June 10, 2019 that Resident 1 was having knee pain. When asked what he knew of the chronic knee pain, PCP A stated he did not know of any chronic knee pain. When asked what the criteria was to notify him of patient condition change, PCP A stated that staff typically called him when needed. During an interview on 06/26/19, at 4:15 p.m., LN D stated she became aware of the complaint of pain in Resident 1's left knee with report from staff on 06/08/19. LN D stated she was told a request for x-ray had been faxed to PCP A. LN D stated Resident 1 received as needed medications for pain. When asked if she had done a nursing assessment of Resident 1's left knee, LN D stated that it was done during medication pass. LN D stated the left knee was not swollen, red, or warm to the touch. During an interview on 06/27/19, at 1:37 p.m., CNA J stated she worked day shift on 06/10/19 and reported Resident 1's complaint of pain and discoloration of her left knee to LN D. CNA J stated she saw redness and displacement of the bone at the side of Resident 1's leg. CNA J stated that when she told LN D what she had observed, she was told an x-ray was up coming. During an interview on 06/27/19, at 1:50 p.m., LN G stated she worked on 06/07/19 and 06/08/19. LN G stated Resident 1 was in pain but that she thought it was probably arthritis, joint pain, or maybe contractures (the shortening or stiffening of muscles, skin, or connective tissues that results in decreased movement and range of motion). LN G stated Resident 1 continued to complain of pain after receiving the medication for pain. LN G stated she saw and spoke to PCP A on 06/10/19, who after reviewing the faxes checked the request for x-ray as yes. When asked why she did not call the doctor, LN G stated, "...Well it really wasn't an emergency." During an interview on 07/02/19, at 8:00 a.m., CNA M stated she received report on 06/07/19 at 11:00 p.m., from the evening shift staff that there was some discoloration, and bruise on Resident 1's left knee. When asked what was observed, CNA M stated she saw purple color on the left knee. CNA M stated both the pain (Resident 1 winced and frowned with movement), and the bruised area of Resident 1's knee was reported to LN H. During an interview on 07/02/19, at 1:17 p.m., LN H stated he worked nights and was working the night of 06/07/19. LN H stated that Resident 1 was in pain, he noted Resident 1's non-verbal indications of pain: facial grimacing, whining with movement, and transitioning to a 2-person assist when she had been a 1-person assist for turning, positioning on the bed-pan, or getting up out of bed. When asked why he did not call the physician, LN H stated that it was a judgement call, as the nurse. During a review of Resident 1's "Interdisciplinary Notes" (where nurses and CNAs document care of residents), dated 06/07/19, LN F worked the 7 a.m. to 3 p.m. shift and received the complaint from Resident 1 of pain. LN F did not document her assessment or interventions. LN G worked the 3 p.m. to 11 p.m. shift, received report from LN F and CNA K of Resident 1's pain. LN G did not document her assessment or interventions. The time of the first note from nursing staff was 11:14 p.m. Resident 1's complaint of pain 9/10 in her left knee happened at 9:00 a.m. During an interview on 07/08/19, at 11:36 a.m., LN F stated she received the complaint of pain level 9/10 from Resident 1 on 06/07/19 at 9:00 a.m.. When asked what her assessment of Resident 1 included, LN F stated that she asked Resident 1 if she had hurt herself. LN F stated that she did not see any disfigurement or discoloration of the left knee. When asked why she did not call PCP A, LN F stated that she endorsed to the next shift to send a fax to PCP A. When asked why there was no documentation of her assessment, LN F stated that she had 12 patients that day, was overwhelmed, and forgot. LN F stated that she had consulted with Family 2 and was told it would be acceptable to wait to notify the doctor, but there was no documentation of that conversation in the medical record. During an interview on 07/08/19, at 1:30 p.m., Family 2 stated that when she arrived on Saturday, June 7, 2019, Resident 1 was sitting in the wheelchair and was wet (as if she had come from a shower). Family 2 stated that Resident 1 was crying, and stated her knee hurt. Family 2 stated Resident 1 was in a lot of pain, and when Family 2 asked her what happened, Resident 1 stated 'somebody fell on me'. Family 2 stated that there was no discussion with LN F in regard to delaying call to PCP A. Family 2 stated that she was told by nursing staff (no names given) the doctor had been called. During an interview on 07/08/19, at 5:45 p.m., CNA L stated that Resident 1 complained of pain both vocally, and with facial expressions, when she said 'my knee hurts' while frowning, but Resident 1 could not tell her what happened. CNA L stated because she did not see any injury to Resident 1's left knee, she reported the pain to LN F and moved Resident 1 from bed to shower chair for her shower, while in pain. CNA L stated Resident 1 was not able to bear weight on her left leg. During a review of the facility documents titled "Licensed Nurse Skills and Competencies", dated 12/23/18, for LN F, included: a three page check-off list of skills, a four page check-off list on orientation, a two-page test on accidents and falls, a one-page test on use of Mechanical Lifts, a one-page test on Abuse, a four-page check-off list for orientation, for a total of 15 pages with the subject of Resident Change of Condition mentioned once, as a check-off item. During a record review for Resident 1, a document titled "Medication Administration Record" for the months of April, 2019; May, 2019; and June 2019 had orders to assess for pain on every shift. During the month of April, 2019, Resident 1 had no documented levels of pain on day, evening, or night shifts, but received as needed pain medication on 04/05/19 and 04/10/19. During the month of May, 2019, Resident 1 had no documented levels of pain on day, evening, or night shifts, and received no medication for pain. During the month of June, 2019, Resident 1 had complaint of pain 9/10 in her left knee on 06/07/19 at 9:00 a.m. Resident 1's pain restricted her movement of the extremity, she was given as needed pain medication, and at the next assessment for pain (4 hours later), the pain level was 7/10 (Pain Level 7-10 Severe Pain; disabling; unable to perform ADLs), but PCP A was not called to report this change of patient status... For more than 60 days prior to 06/07/19 Resident 1 had no complaint of pain greater than 4/10 (Pain Level 4-6 Moderate Pain; interferes significantly with ADLs). During a record review for Resident 1, a document titled "Medication Administration Record," dated, June 2019, the as needed pain medication was ordered to be given every 8 hours until 06/10/19. LN E, and LN F gave the as needed pain medication every 4 hours on 06/07/19 and 06/08/19 without an order from PCP A. On 06/10/19 PCP A changed the as needed dose time to every 4 hours. During a review of the American Journal of Nursing article titled, "Assessing and Managing Acute Pain", dated March 2017, indicated: "Acute pain, which is usually sudden in onset...The authors call on nurses to assess and manage acute pain in accordance with evidenced-based guidelines...Nurses assume an essential role in caring for patients with acute pain and in preventing that pain from transitioning to chronic pain. Nurses must advocate for patients to receive optimal treatment of acute pain and collaborate with other health care team members to design and administer care plans that promote comfort; facilitate recovery, restore physical, emotional, and social health; and lead to the best possible patient outcomes..." The facility document titled "Job Analysis and Description for Charge Nurse, LVN and RN" dated January, 2016, indicated: "...14. Consults with the residents physician in planning residents care, treatment, and rehabilitation. 15. Notifies the residents attending physician and next of kin when there is a change of resident's condition..." The facility policy and procedure titled "Pain Assessment and Management", dated March, 2015, indicated: " General Guidelines: ...Assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain..." The facility policy and procedure titled "Change of Status Notification", dated, May 2017, indicated: "Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition...1. The nurse will notify the resident's Attending Physician or physician on call when there has been an. a. accident or inci