Health inspection·February 28, 2025

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 observation, interview, and record review, the facility failed to have physician prescribed narcotic pain medication for 1 of 3 residents (R2) reviewed for pain. This failure resulted in the resident experiencing severe pain, becoming incontinent of bowel and bladder, and displaying agressive behaviors. Residents Affected - Few Findings include: R2's Undated Face Sheet documents he was admitted to the facility on [DATE], with diagnoses including spinal stenosis, pain thoracic spine, low back pain, and chronic pain syndrome. R2's Care Plan documents, focus pain alteration in comfort related to the advanced disease process, chronic physical or psychological disability, musculoskeletal, neurological issues due to diabetic neuropathy and osteoarthritis of the right hip. Goal: resident will not experience a decline in overall function r/t (related to) pain through next review. Will maintain adequate levels of comfort as evidence by no s/s (signs or symptoms) of unrelieved pain or distress, verbalizing satisfaction or expressing with relief and comfort throughout next review. Interventions: administer pain meds, assess effectiveness of pain medication, assess pain characteristics: duration, location, quality. R2's admission Pain Evaluation, dated 12/26/2024, documents pain diagnoses spinal stenosis, myelopathy and right hip pain. Hurts a whole lot describes pain as radiating, stabbing, tightness and tingling. Other comments: has a history of threatening suicide when experiencing pain. R2's Quarterly Minimal Data Set (MDS) documents he is alert and had pain. R2's Physician's Order Sheet (POS), dated 1/2025, documents 1/6/2025 Oxycodone 20 mg every eight hours. R2's Medication Administration Record (MAR), dated 1/2025, documents 9 other see nurse's note for the following dates and times: 1/30/2025 at 2:00 PM and 10:00 PM and on 1/31/2025 at 6:00 AM. R2's Nurse Progress Note, dated 1/30/2025, had no documentation regarding narcotic pain medication for 2:00 PM and 10:00 PM. R2's Nurse Progress Note, dated 1/31/2025 at 1:31 PM, V3, Registered Nurse (RN), documented, resident c/o nausea and several stools today. He has not had his pain medicine-prob side effect of that. Explained to resident with understanding verbalized. R2's Nurse Progress Note, dated 1/31/2025 at 3:40 PM, V3 documented, 2:30 PM Resident up to desk Page 1 of 3 145656 145656 02/28/2025 Bria of Godfrey 1623 29 West Delmar Godfrey, IL 62035

F 0697 Level of Harm - Actual harm Residents Affected - Few yelling, demanding his pain medicine which we did not have but were ordered. He could not be redirected or calmed regarding situation becoming louder and throwing things. 911 called however resident refused to go to hospital. DON (Director of Nursing) trying to get his pain medicine sooner. On 2/28/2025 at 9:33 AM, V5, Certified Nurse Aide (CNA), stated, (R2) uses a urinal and a bed side commode for bowel movements; he is not incontinent, and he is up in his wheelchair self-propelling about the facility most of the day. On 2/28/2025 at 9:50 AM, V6, CNA, stated R2 is continent of bowel and bladder and is usually up in his wheelchair, but at the end of January 2025, she was working and was assigned to (R2), and he was very upset that he didn't have his pain medication. He was incontinent of bowel and bladder and was curled up in bed at that time. On 2/28/2025 at 9:58 AM, V7, CNA, stated, (R2) is continent of bowel and bladder and he is usually up in his wheelchair. On 2/27/2025 at 2:45 PM V3, RN stated she recalled R2's narcotic pain medication wasn't available at the end of January 2025, but it was on the way to the facility, and she told him. He was really mad and was having side effects from not having the medication, which was incontinent loose stools that day due to the pain he was experiencing. On 2/27/2025 at 11:48 AM, R2 stated he uses the urinal for bladder, and a bed side commode for bowel moments and is up in his wheelchair self-propelling about the facility. (R2) stated he went several days without his narcotic pain medication at the end of January 2025. Because he didn't have it, he was curled up in the fetal position s****ing all over himself all day. The nurse (name unknown) came in and told him he was feeling so bad because the facility didn't have his narcotic pain medication, and it was on the way from the pharmacy in (city). He was very upset he didn't have his narcotic pain medication available at that time. He stated he went through h*** those two days because he was in such pain; his body was breaking down, and it takes what feels like forever to get out of that severe pain because the pain is so severe it takes several doses of his narcotic pain medication to catch up in his body to start to relive the pain again. On 2/27/2025 at 1:10 PM, V2, Director of Nurses (DON), stated she wasn't aware any residents, including (R2), missed three consecutive doses of narcotic pain medication because it wasn't available at the facility. She expected staff to call her so she could work on getting the narcotic pain medication delivered to the facility as soon as possible. The nurse should have notified the pharmacy, and if the facility had a signed prescription on file, then the pharmacy would have sent a code and the facility staff could have accessed the medication in the emergency kit. On 2/27/2025 at 3:30 PM, V2 stated R2 is alert and is usually continent of bowel and bladder. V2 recalled the day R2 missed a few doses of his narcotic pain medication because he was up at the nurse's station calling her a f****** b**** and everything but a white woman. At that time, she wasn't aware R2 missed three doses of his narcotic pain medication and he was out of control. Facility staff called the police because R2 was so upset, cursing and yelling at everyone. R2 usually contacts her when he is out of his narcotic pain medication, and she was shocked he didn't come to her sooner and let her know he was out of it. V2 stated when staff realized he was out of narcotic pain medication on 1/30/2025, they printed a prescription and put it in the folder for the Nurse Practitioner to sign on 1/31/2025, but she didn't come to the facility that day, so the prescription wasn't signed. 1/31/2025 was the day R2 snapped on the staff and she got the pharmacy to send her a code, and she got 145656 Page 2 of 3 145656 02/28/2025 Bria of Godfrey 1623 29 West Delmar Godfrey, IL 62035

F 0697 a dose of R2's narcotic pain medication from the emergency medication kit. R2 calmed down after receiving the pain medication. Level of Harm - Actual harm Residents Affected - Few On 2/27/2025 at 12:20 PM, V4, Nurse Practitioner, stated she expected all physician ordered medication to be available at the facility, and she expected staff to follow facility policies on medication administration. On 2/28/2025 at 9:00 AM, V4, Nurse Practitioner, stated she wasn't aware R2 went without narcotic pain medication for three doses at the end of January 2025. Although he has a lot of comorbidities including spinal stenosis, which is very painful, if he was usually continent of bowel and bladder and up in his wheelchair propelling about the facility then became incontinent of bowel and bladder and in the fetal position in bed due to not having pain medication, that could potentially cause these side effects due to not having the narcotic pain medication. The Facility's Medication Administration Policy, revised 5/2017, documents, if medication is not given as ordered, document the reason on the MAR and notify the Health Care Provider if required. if medication is ordered, but not present, check to see if it was misplaced and then call the pharmacy to obtain the medication. If available, obtain it from the contingency or convenience box. 145656 Page 3 of 3