Health inspection·June 27, 2024

Health & Safety Code § 1254.7 (a) (b) (a) It is the intent of the Legislature that pain be assessed and treated promptly, effectively, and for as long as pain persists. (b) A health facility licensed pursuant to this chapter shall, as a condition of licensure, include pain as an item to be assessed. The health facility shall ensure that pain assessment is performed in a consistent manner that is appropriate to the patient. The pain assessment shall be noted in the patient's chart. On 1/24/23, at 10:30 AM, an unannounced visit was conducted at the facility to investigate a complaint regarding care provided for residents receiving hospice care. The facility admitted Resident 1, a 64-year-old male, on 5/19/22. Resident 1's diagnoses included: generalized muscle weakness, chronic (permanent) kidney disease, respiratory (insufficient oxygen or excess carbon dioxide [waste product of breathing] in the blood) failure, type 2 diabetes mellitus (body unable to regulate and use sugar as fuel) with nerve damage, osteoarthritis (breakdown of the joints causing pain), and displaced left femur fracture (broken leg bone). Based on interview and record review, the facility failed to re-assess Resident 1's pain and provide pain medication according to physician's orders to treat breakthrough pain (a sudden increase in or exacerbation of pain that may occur in residents despite having a stable and well controlled chronic pain regimen). This failure resulted in Resident 1 experiencing uncontrolled moderate to severe pain during a terminal illness (illness that cannot be cured and is expected to end in death). The facility failed to adhere to Health and Safety 1254.7 (a)(b). Findings: During an interview on 2/26/24 at 10:18 a.m. with Resident 1, Resident 1 stated he had "a lot of issues with pain, especially at night." Resident 1 stated he did not feel like staff managed his pain.[DS1] During a review of Resident 1's Minimum Data[DS2] Set (MDS- comprehensive assessment tool) "Brief Interview for Mental Status" (BIMS- an assessment used to determine the ability to think and remember BIMS of 13-15 indicates no cognitive impairment, 8-12 indicates some cognitive impairment but still able to make needs known, 0-7 indicates severe cognitive impairment), dated 12/18/23, Resident 1's BIMS indicated, Resident 1 had moderate cognitive impairment (score of 10). During a review of Resident 1's Order Summary Report (OSR), dated 2/26/24, the OSR indicated, "Acetaminophen [Tylenol, used to relieve mild to moderate pain] Extra Strength Oral Capsule 500 MG [milligrams] (Acetaminophen) Give 1 capsule by mouth three times a day for pain management. . . Acetaminophen. . . Give 2 tablet by mouth every 8 hours as needed for PAIN SCALE 1-4 [pain screening tool used to assess pain severity at that moment in time using a 0-10 scale where zero indicates no pain, 1-3 indicates mild pain, 4-6 indicates moderate pain, and 7-10 indicates severe pain]. . . Morphine Sulfate [medication used to treat moderate to severe pain]. . . Give 0.25 ml [milliliters] by mouth every 1 hours as needed for pain or breathlessness. During a concurrent interview and record review on 2/26/24 at 1:24 p.m. with Director of Nursing (DON), Resident 1's Weights and Vitals Summary (WVS), dated December 2023, January 2024 and February 2024 were reviewed. The WVS[DS3], dated December 2023 indicated, Resident 1 complained of pain using a pain scale on the following dates and times: 12/24/23 at 8:25 a.m[DS4]. pain of 5 out of 10 (5/10 ) 12/24/23 at 1:23 p.m. pain of 4/10 12/24/23 at 5:07 p.m. pain of 8/10. The WVS indicated, staff did not reassess Resident 1's pain level until 12/25/23 at 9:35 a.m. 5/10. (16 hours later). 12/26/23 at 9:02 a.m. pain of 5/10 12/27/23 at 5:02 p.m. pain of 7/10. The WVS indicated, staff did not reassess Resident 1's pain level until 12/28/23 at 8:42 a.m. (16 hours later). The WVS[DS5], dated January 2024 indicated, Resident 1 complained of pain using a pain scale on the following dates and times: 1/31/24 at 8:52 a.m. pain of 6/10 1/30/24 at 9:13 a.m. pain of 6/10 1/25/24 at 4:14 p.m. pain of 4/10 1/24/24 at 5:48 p.m. pain of 5/10 1/24/24 at 8:44 a.m. pain of 6/10 1/19/24 at 7:56 a.m. pain of 6/10 1/18/24 at 9:36 a.m. pain of 6/10 1/13/24 at 8:53 a.m. pain of 6/10 1/12/24 at 12:42 p.m. pain of 5/10 1/12/24 at 8:36 a.m. pain of 6/10 1/7/24 at 8:30 a.m. pain of 6/10 1/7/24 at 12:49 p.m. pain of 4/10 1/6/24 at 9:39 a.m. pain of 5/10 1/1/24 at 4:43 p.m. pain of 6/10 The WVS[DS6], dated February 2024 indicated, Resident 1 complained of pain using a pain scale on the following dates and times: 2/23/24 at 8:40 a.m. pain of 6/10 2/18/24 at 8:45 a.m. pain of 6/10 2/17/24 at 4:19 p.m. pain of 6/10 2/17/24 at 8:24 a.m. pain of 6/10 2/14/24 at 9:08 a.m. pain of 7/10 2/12/24 at 5:02 p.m. pain of 4/10 2/11/24 at 12:35 p.m. pain of 4/10 2/11/24 at 9:14 a.m. pain of 6/10 2/6/24 at 9:02 a.m. pain of 6/10 2/5/24 at 4:20 p.m. pain of 4/10 2/5/24 at 8:46 a.m. pain of 8/10 During a concurrent interview and record review on 2/26/24 at 1:41 p.m. with DON, Resident 1's Medication Administration Record (MAR), dated December 2023, January 2024 and February 2024 were reviewed. The MAR[DS7]s, dated December 2023, January 2024 and February 2024 all indicated, "Acetaminophen. . . Give 2 tablet by mouth every 8 hours as needed for PAIN SCALE 1-4. . . Morphine Sulfate. . . Give 0.25 ml by mouth every 1 hours as needed for pain or breathlessness." DON stated Resident 1 should have been given something for breakthrough pain if routine pain medications were not effective. DON stated neither the morphine[DS8] nor the Tylenol, prn (to be used as needed), were administered for breakthrough pain anytime in December 2023, January 2024, or February 2024 when Resident 1 complained of moderate to severe pain[DS9]. During a concurrent interview and record review on 2/26/24 at 1:58 p.m. with Licensed Vocational Nurse (LVN) 2, Resident 1's MARs, dated December 2023, January 2024 and February 2024 were reviewed. The MAR[DS10]s, dated December 2023, January 2024 and February 2024 indicated, Resident 1 had complained of moderate to severe pain on multiple occasions. LVN 2 stated Resident 1 had Tylenol and "liquid morphine for breakthrough pain." LVN 2 stated Resident 1 should have gotten the liquid morphine if he was complaining of pain 6[DS11]/10, 7/10, or 8/10. During a concurrent interview and record review on 2/26/24 at 2:02 p.m. with LVN 2, Resident 1's clinical record (CR) was reviewed. LVN 2 was unable to locate any documentation or progress note indicating Resident 1's pain was addressed. LVN 2 stated there was no documentation in the clinical record "that hospice [program that provides pain and symptom relief to people who are near the end of life] was notified, or a non-pharmacological [intervention that does not involve the use of medicine]" was used to alleviate pain on the days Resident 1 complained of moderate to severe pain in December 2023, January 2024, or February 2024. During an interview on 2/26/24 at 2:07 p.m. with LVN 1, LVN 1 stated when she administered routine Tylenol to Resident 1, the system triggered her to document the resident's pain level. LVN 1 stated she was not required to re-assess pain level after administration of routine pain medication. LVN 1 stated she re-assessed pain level if the medication was given as needed (PRN) because only PRN orders trigger her to re-assess the pain level. During an interview on 2/28/24 at 2:08 p.m. with Registered Nurse Case Manager (RNCM), RNCM stated she worked for the hospice company, she visited Resident 1 about twice a week. RNCM stated Resident 1 complained of pain a lot more at night last September, so the physician increased his morphine from 2 times a day to 3 times a day. RNCM stated Resident 1 sometimes complained of pain in his left arm even with the routine pain medications. RNCM stated Resident 1 would benefit from the PRN pain medications and she and the other hospice nurses had previously educated the facility licensed nurses about utilizing the morphine PRN. RNCM stated Resident 1 was alert and able to verbalize his needs. During a review of Resident 1's "Nursing Summary Notes" (Hospice NSN), dated 12/11/23, the NSN indicated, "Education provided to Staff on giving the Morphine Sulfate PRN in between the routine one [morphine]. . .Staff verbalizes understanding." During a review of Resident 1's "Notes on Pain" (NOP), dated 12/20/23, the NOP indicated, "Patient reporting pain to back, states it is all the time. [LVN 2] located and reports patient receives MSER [Morphine Sulfate Extended Release- medication released over a period of time] TID [three times a day] and has not been using MSIR [Morphine Sulfate Instant Release] Advised to offer to patient." During a review of Resident 1's care plan (CP), dated 8/7/23, the CP indicated, "Anticipate the resident's need for pain relief and respond immediately to any complaint of pain." During a review of Resident 1's care plan (CP), dated 10/25/23, the CP indicated, "Observe resident closely for signs of pain, administer pain medications as ordered, and notify physician immediately if there is breakthrough pain." During a review of the facility's policy and procedure (P&P) titled, "P-PA01 Pain Management," dated 05/25/23, the P&P indicated, "1. Pain Assessment a. A pain assessment will be completed for each resident upon admission, quarterly, when there is a new onset of pain, exacerbation of pain, or when there is a significant change in status. b. The Licensed Nurse will complete a Pain Assessment for residents identified as having pain. . . 2. Pain Management a. The Licensed Nurse will administer pain medication as ordered and document medication administered on the Medication Administration Record (MAR) b. After medications/interventions are implemented, the licensed nurse will re-evaluate the resident's [sic] level of pain within one hour. c. The Licensed Nurse will assess the resident for pain and document results on the MAR each shift d. If there is a new onset of pain, if the pain has changed in nature, or the pain has not been relieved with current medication, the Licensed Nurse will notify the Attending Physician. . . 4. Documentation a. Pain Assessments will be maintained in the resident's medical record. b. The Licensed Nurse will document resident's pain level and response to interventions in the medical record. c. The Licensed Nurse will update the Care Plan for pain management with any change in treatment and/or medication." In violation of the above citated standards, the facility failed to ensure staff followed the facility policy and procedure for pain management and re-assessment of Resident 1's chronic pain due to a terminal illness. This failure resulted in Resident 1 experiencing uncontrolled moderate to severe pain during a terminal illness. This violation had a direct or immediate relationship to the health, safety, or security of Resident 1 and constitutes a Class "B" citation. [DS1]Consider Resident 1 stated he did not feel like staff managed his pain [DS2]Data - [DS3]Which WVS [DS4]Consider adding pain of [DS5]Which WVS [DS6]Which WVS [DS7]Which MAR, you reviewed 3 months You have to be specific this is an A citation [DS8]Are these PRN or Scheduled. It is confusing because you have what appears to be a schedule medication above in your first drug order review [DS9]DON stated the MARs dated 12/2023, 1/2024 and 2/24, did not indicate licensed nurses provided either as needed (prn) morphine or prn Tylenol at any time during 12/23, 1/24 or 2/24 when Resident 1 complained of moderate to severe pain. [DS10]Again which MAR [DS11]Consider 6/10, 7/10, 8/10