Health inspection·February 2, 2024

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide pain management for one of three residents (R2) reviewed for pain management in the sample of six. This failure resulted in R2 having to endure increased untreated pain for a prolonged period of time Residents Affected - Few Findings Include: R2's Minimum Data Set, dated [DATE], documented that R2 is cognitively intact. R2's Pain Care Plan, dated 8/8/23, documented, (R2) has complaint of pain at times related to Osteoarthritis. The nursing (staff) monitors his pain each shift and prn (as needed). He (R2) is offered pain medications as per medical doctor orders. On 1/30/24 at 11:30 AM, R2 stated, I hurt a lot. I have to take pain medicine R2's Physicians Order Sheet (POS), dated 12/29/23, documented that R2 was admitted to hospice with a diagnosis of Colon Cancer. R2's POS, dated 1/18/24, documented, Morphine Sulfate 20 mg (milligrams)/ML (Milliliters) by mouth in the morning every Monday, Wednesday, and Friday prior to Dialysis. R2's POS, dated 1/2/24, documented, Tramadol 50 mg 1 tablet every 4 hours when needed for pain. R2 POS, dated 1/8/24, documented, Morphine sulfate 20 mg/ml give 0.25 ml by mouth every one hour as needed for pain. R2's Nurses Note, dated 1/24/23 at 1:21 AM, documented, Received call from night nurse that evening shift agency nurse must have took med cart (medicine cart) keys home with her. Call placed to (Agency) representative and (Facility's) Pharmacy, message left for both to call this writer back. Call placed to administrator and updated on situation. R2's Nurses Note, dated 1/24/23 at 08:49 AM, documented, Call placed to (Facility's) Pharmacy, request to receive extra set of keys to lock box on each med cart for back up. Faxed over ID information on each lock box, pharmacy will send out keys. R2's Nurses Note, dated 1/24/23 at 9:52 AM, documented, Call placed to agency nurse that worked evening shift prior, to check once she gets home for keys. Page 1 of 2 145410 145410 02/02/2024 Evercare of Breese 1155 North First Street Breese, IL 62230

F 0697 R2's Nurses Note dated 1/24/23 at 3:50 PM agency nurse returned keys to the facility. Level of Harm - Actual harm On 1/31/24 at 3:00 PM, V2, Director of Nursing, stated, He (R2) did not receive his medications on the morning of 1/24/24 due to not having keys to the lock box. Residents Affected - Few On 1/31/24 at 1:17 PM, V13, Dialysis Nurse, stated, When he returned from the hospital, the family decided to continue dialysis even though he is on hospice, but his pain was not in control. The treatment team decided that he would receive morphine before leaving the facility on Monday, Wednesday, and Friday. On the 24th of January (R2) came to dialysis, but he was complaining of pain and hollering out. I gave him Tylenol, but it did not help. He is usually in a lot of pain. I called the facility, and they stated they didn't have keys to get into the lock box to give him medications. We had to stop his treatment, because he was yelling I want to go home I'm hurting. We sent him back to the facility, but he usually carries a lot of fluid. I set up a dialysis on Saturday, but it wasn't ideal because they were only going to remove the fluid. On 2/1/24 at 11:01 AM, V15, Nurse Practitioner, stated, From my perspective yes he (R2) should have received it (pain medications). The inability to get it, they should have reached out to hospice or our office. If he didn't complete dialysis because of pain that's a problem. I don't believe it is detrimental to him (to miss dialysis). He does very well with his blood pressure and electrolytes. It's not great that he missed a day, but it's not detrimental. The Facility's Pain Policy, undated, documented, 1. To provide effective pain assessment and management that helps remove the adverse psychological and physiological effects of unrelieved pain. It continues, 4. To ensure optimal patient comfort through a proactive pain control plan, which is mutually established with the patient, family, and members of the health care team. 145410 Page 2 of 2