Other·October 15, 2021

HSC 1424 (d) Class "A" violations are violations which the state department determines present either (1) imminent danger that death or serious harm to the patients or residents of the long-term health care facility would result therefrom, or (2) substantial probability that death or serious physical harm to patients or residents of the long-term health care facility would result therefrom. A physical condition or one or more practices, means, methods, or operations in use in a long-term health care facility may constitute a class "A" violation. The condition or practice constituting a class "A" violation shall be abated or eliminated immediately, unless a fixed period of time, as determined by the state department, is required for correction. Except as provided in Section 1424.5 , a class "A" citation is subject to a civil penalty in an amount not less than one thousand dollars ($1,000) and not exceeding ten thousand dollars ($10,000) for each and every citation. 42 CFR §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. 72311. Nursing Service - General. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A)Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B)Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. On 6/24/21, an unannounced visit was conducted at the facility to investigate a facility reported incident of patient injury. This failure resulted in Resident 1 experiencing unresolved pain due to a broken hip for approximately 12 hours during which she would scream and moan with pain, and swat away staff during provision of care. Resident 1 was a 95-year-old female, who was admitted to the facility 4/27/2012. Resident 1's diagnoses included generalized muscle weakness, need for assistance with personal care, cognitive (difficulty communicating due to injury to the brain that controls the ability to think, memory processes, organization and problem solving) communication deficit, dysphagia (difficulty swallowing), dementia (disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) repeated falls, chronic pain, Adult failure to thrive, dysthymic disorder (loss of interest in normal daily activities, feel hopeless, lack productivity, and have low self-esteem and an overall feeling of inadequacy), and Disorder of bone density and structure (weakened bone structure). Resident 1 had severely impaired thinking ability and memory. During an interview on 6/24/21, at 1 PM, with the Director of Nursing (DON), DON stated, the facility transferred Resident 1 to the acute hospital on 12/13/20 and the hospital diagnosed her with a left hip fracture. DON stated, Resident 1 did have some pain on 12/12/20. During an interview on 6/24/21, at 3:10 PM, with Certified Nursing Assistant (CNA) 1, CNA 1 stated, she had worked directly with Resident 1 on 12/12/20 starting around 2:45 PM until 11:15 PM that night. CNA 1 stated, Resident 1 was fine until after dinner time (after 5 PM). CNA 1 stated, after dinner time she went into Resident 1's room to change her brief and noticed Resident 1's left hip was "Swollen." CNA 1 stated, the left hip was bigger than the right hip. CNA 1 stated, when she would move Resident 1 in bed, Resident 1 would moan out in pain. CNA 1 stated, together with CNA 2, she informed Registered Nurse (RN) 1 of a change to Resident 1's hip and her pain. CNA 1 stated, RN 1 instructed her to keep an eye on Resident 1 and not place Resident 1 on her left side. CNA 1 stated, it was facility practice to check, change, and reposition residents every two hours. CNA 1 stated, for the rest of her shift she did not place Resident 1 on her left side. CNA 1 stated, whenever CNAs moved Resident 1, she moaned and showed signs and symptoms of pain. CNA 1 stated, she did not tell RN 1 again about Resident 1's moaning in pain because he was already aware of it. During an interview on 6/29/21, at 1:48 PM, with CNA 2, CNA 2 stated, she had worked from 2:45 PM to 11:15 PM on 12/12/20. CNA 2 stated, Resident 1 required two CNAs to assist with care instead of her usual one CNA because of the amount of pain she was in when they would move her. CNA 2 stated, Resident 1 would scream in pain and strike out at staff with any type of movement throughout the shift. CNA 2 stated, they (CNAs) moved and repositioned Resident 1 every two hours. CNA 2 stated, they would use a pillow to move her left leg to attempt to minimize the amount of pain she was experiencing. CNA 2 stated, when in pain Resident 1 would exhibit pain on a scale of eight or nine out of ten (zero being no pain, five being moderate pain, and ten being unbearable excruciating pain). CNA 2 stated, she would report to RN 1 about Resident 1's pain every time they moved her. CNA 2 stated, RN 1 instructed her not to place Resident 1 on her left side. CNA 2 stated, they endorsed (reported) Resident 1's pain and left leg issues to the next shift to make them aware. During an interview on 6/29/21, at 2:07 PM, with RN 1, RN 1 stated, he was the nurse in charge of Resident 1 on 12/12/20. RN 1 stated, CNA 1 had called him to check on Resident 1 around 4 PM. RN 1 stated, he noticed Resident 1 crying out in pain and grimacing with movement. RN 1 stated, Resident 1's left leg was "Slightly swollen." RN 1 stated, he did not contact the Medical Doctor (MD) for Resident 1 because he did not consider it a change in condition for Resident 1. RN 1 stated, he did not check Resident 1's history or her care plans to help understand Resident 1's baseline status (the persons normal state of health). RN 1 stated, he did not try to move Resident 1's left leg because she would "swat us away when we tried to move it." RN 1 stated, the CNAs never told him that Resident 1 was in pain throughout the shift. RN 1 stated, if he was aware Resident 1 was in pain, he would have given Resident 1 pain medication. RN 1 confirmed, he did not give Resident 1 pain medication nor inform the MD of any left leg/hip issues. During an interview on 7/8/21, at 2:25 PM, with CNA 3, CNA 3 stated, she had worked with Resident 1 on the day Resident 1 was sent to the hospital (12/13/20). CNA 3 stated, she worked the morning (6:45 AM to 3:15 PM) shift. CNA 3 stated, CNA 4 reported to her Resident 1 was in pain with movement. CNA 3 stated, LVN 2 then said he was going to send Resident 1 to the hospital because something was noticeably wrong with Resident 1's left leg. CNA 3 stated, Resident 1 did not want to be touched. CNA 3 stated, Resident 1's pain level would be at a nine or ten out of ten when she was awake or being moved. During an interview on 7/23/21, at 8:27 AM, with CNA 4, CNA 4 stated, he worked the night shift on 12/12/20 to the morning of 12/13/20 (10:45 PM to 7:15 AM). CNA 4 stated, he was assigned Resident 1. CNA 4 stated, Resident 1's left leg/hip was "really noticeable and bulging out." CNA 4 stated, Resident 1 was in pain only when moving or changing her. During a review of Resident 1's "Care Plan," [undated], the "Care Plan" indicated, Resident 1 had a high risk for injuries, deformities, spontaneous fractures (break in bone occurring without injury) and pain related to osteopenia (bone loss). The "Care Plan" indicated, "Observe for joint bone pain and stiffness and notify MD accordingly." During a review of Resident 1's "History and Physical Report" (H&P), dated 12/13/20, the "H&P" indicated Resident 1 had a left hip fracture confirmed by x-ray. During a review of Resident 1's Medication Administration Record (MAR - a legal record of the drugs administered to a patient at a facility by a health care professional), dated 12/1/21 through 12/31/21, the MAR indicated the following: a. "Monitor for pain Q [every] shift using the following numerical pain scale: 0 = No Pain, 1-3 = mild pain, 4-6 = mod [moderate] pain, 7-10 = severe pain ...nonpharmacological [other than medication] interventions: 0 - not applicable 1 - Heat/Cold compress 2 - positioning ..." The MAR indicated on 12/12/21, Resident 1 had a pain score of 0 for all three shifts and NA (not applicable) for nonpharmacological interventions (NPI). b. "NOTE EPISODE of striking out/physical aggressiveness ..." The MAR indicated, between 12/1/20 and 12/12/20, Resident 1 had no acts of striking out or physical aggressiveness on any shift. c. "NOTE EPISODE of verbally aggressively/yelling ..." The MAR indicated, between 12/1/20 and 12/12/20, Resident 1 had no acts of verbal aggressiveness or yelling on any shift. During a review of Resident 1's Progress Notes, dated 12/13/20, at 3:06 AM, the Progress Note indicated, "L [left] hip swelling with no bruising. Resident c/o [complain of] pain and discomfort when moving lower extremities [legs] ...Repositioning gives comfort." During a review of Resident 1's Progress Notes, dated 12/13/20, at 10:20 AM, the Progress Note indicated "Resident noted to c/o pain to the left hip when reposition and when care is provided. Upon evaluation resident noted to have a prominence [bump, swelling] hard to touch and tender to the left hip." In violation of the above cited standards, the facility failed to ensure pain management was provided to Resident 1 consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious harm would result and represents a class A Citation.