Health inspection·December 5, 2024

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for 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 (R3) reviewed for pain in the sample of 5. This failure resulted in R3 not receiving pain management for a fall with serious injury for 24 hours. This past non-compliance occurred from 11/16 until 11/18/24. Residents Affected - Few Finding Include: R3's Minimum Data Set (MDS) dated [DATE] documents R3 is severely cognitively impaired, and R3 requires substantial to maximum assistance. R3's MDS dated [DATE] documents R3 is moderately cognitively impaired. R3 needs partial assistance from another person for any activities. R3's Electronic Health Record documents R3 has diagnoses of FX (Fracture) of Unspecified Part of Neck of Left Femur and Traumatic FX. R3's Pain Care Plan 11/13/24 documents R3 has potential for pain related to unstable angina and COPD (Chronic Obstructive Pulmonary Disease) Interventions: anticipate the residents need for pain relief and respond immediately to any complaint of pain. Observe report to nurse any S/SX (signs and symptoms) of nonverbal pain. R3's Fall Investigation dated 11/17/24 documents resident (R3) noted to have witnessed fall (CNA) (certified nursing assistant) V9 resident noted to fall on her left side of body, head, shoulder hip, and leg. No obvious signs of trauma to left hip, left shoulder, and left leg PERRLA (pupils are equal round and reactive to light and accommodation) within normal limits for this resident. Pupils equal and brisk. No c/o (complaint of) headache or discomfort, able to move all extremities as prior. Adduction and abduction without issues and WNL (within normal issues) for this resident. Bruising to left upper lip and posterior facial cheek. No gait alterations noted, no difficulties ambulating, no indication of further emergent medical need at this time. MD (Medical Doctor) updated, POA (Power of Attorney) updated and nurse. Intervention: place pressure pad alarm in bed. R3's Left Femur Left Hip X-ray dated 11/18/24 at 5:32 PM documents slightly impacted subcapital FX of femoral neck. Impression impacted subcapital FX. R3's Medication Administration Record (MAR) for the month of November documents Pain assessment not completed for November 16-21. R3's November 2024 MAR documents Pain record highest level of pain Q (every) shift, 11/16 on days R3's pain was a 10 on day shift. R3 was not given pain medications on 11/16/24. On 11/17 pain was not evaluated, and pain medications were not given on 11/17/24. On 11/18/24, R3's pain was rated a 6 on Page 1 of 2 145508 145508 12/05/2024 Highland Health Care Center 1450 26th Street Highland, IL 62249

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few days and evenings; however, R3 was not given pain medications on this day. On 11/19 R3's pain was a 6 on days and evenings, on 11/20/24 R3's pain was a 6 on days and evening; however, R3 was at the hospital and not residing at the facility. R3's MAR also documents R3 was given Tylenol 325 milligrams (mg) two tablets Q (every) 6 hours PRN (as needed) and was given on 11/22 for a pain level of 2 and it was effective. R3 was not given any pain medication on 11/18 although her pain was rated at a 6. R3's MAR documents Tramadol 50mg Q 8 hours PRN for chronic pain was last given on the 10th of November. R3's Physician Order Sheet (POS) dated 5/14/24 documents Norco 5/325mg (milligrams) give one tablet by mouth every 6 hours as needed for pain. Do not exceed 4 GM (grams) daily. R3's POS dated 11/20/23 documents Tramadol 50mg 1 tablet every 6 hours as needed for pain. R3s POS dated 11/22/24 documents Acetaminophen 325mg give 2 tablets by mouth every 4 hours as needed for pain fever. R3's After Visit Summary from a local hospital documents R3 was discharged on 11/22/24. On 12/3/24 at 3:50 PM, V2 Director of Nursing stated, I recognized there was a problem, and I did a plan of correction right away. Everyone was in serviced on Pain Management. On 12/5/24 at 9:36 AM, V12 Physician stated, absolutely I expect her (R3) pain to be treated, if she (R3) complained. The facility policy Management of Pain dated 5/16/22 documents promptly and accurately assessing and diagnosing pain. Encourage the resident to self-report pain. Prior to the survey date, the Facility took the following actions to correct the noncompliance on 11/18/24. Immediate Actions: 1.The facility in serviced all nurses regarding pain management and the administration of pain medications on 11/18/24. This was completed by V2. 2. The facility added pain management as an action plan to quality assurance as well as monitoring compliance beginning on 11/18/24. 145508 Page 2 of 2