Health inspection·October 18, 2024

Class A Citation- Pain Management California Code Regulations, Title 22, section 72313 Nursing Services - Administration of Medications and Treatments. (a) Medications and treatments shall be administered as follows: (2) Medications and Treatments shall be administered as prescribed. California Code Regulations, Title 22, section 72353 Pharmaceutical Service- General. (a) Arrangements shall be made to assure that pharmaceutical services are available to provide patients with prescribed drugs and biologicals. California Code Regulations, Title 22, Section 72355 Pharmaceutical Service- Requirements. (a) Pharmaceutical Service shall include, but is not limited to, the following: (1) Obtaining necessary drugs including the availability of 24-hour prescription service on a prompt and timely basis as follows: (B) Anti-Infectives and drugs used to treat severe pain, nausea, agitation, diarrhea, or other severe discomfort shall be available and administered within four hours of the time ordered. California Code Regulations, Title 22, Section 72523 Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. Code of Federal Regulation, Title 42, 483.25 (k) Pain Management. 483.25 (k) The facility must ensure that pain management is provided to a patient who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the patient’s goals and preferences. On August 16, 2024, at 8:30 a.m., an unannounced visit to the facility was conducted to investigate a quality care issue. It was determined that the facility failed to: 1. Ensure pain medications necessary for the care and treatment of Patient A was made available during admission at the facility; and 2. Ensure pain medications were administered in accordance with the physician order for Patient A who undergone a spinal compression surgery (a procedure that relieves pressure on the spinal cord or nerves) and was admitted to the facility for pain management and physical therapy. As a result of these failures, Patient A experienced severe back pain for two days, from August 14 to August 16, 2024, and was transferred to the general acute care hospital (GACH) on August 16, 2024, for pain management. On August 16, 2024, at 9:15 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated Patient A was admitted to the facility on August 14, 2024, after 3 p.m. The DON stated Patient A had a spinal compression surgery and was on pain medications. She stated Patient A started asking for pain medications by 5 p.m., the day of Patient A’s admission on August 14, 2024; however, the DON stated Patient A's pain medications were not available. On August 16, 2024, at 10:30 a.m., a concurrent observation and interview was conducted with Patient A. Patient A stated she was not "doing okay" and wanted out of the facility. Patient A stated she was in pain and the nurses were not giving her the medication she needed. Patient A stated she asked for pain medication upon admission on August 14, 2024, at around 4 p.m., and the patient stated she waited several hours and received pain medication on August 15, 2024, at around 4 a.m. Patient A was observed crying, and her voice was raised as she spoke. Patient A stated that she wanted to feel better, and her legs were having spasms (sudden involuntary muscular contractions) which was causing so much pain. Patient A was observed to be wincing as she grabbed her leg and continued to cry. On August 16, 2024, Patient A's Admission Record was reviewed. Patient A was admitted to the facility on August 14, 2024, with diagnoses which included orthopedic (branch of medicine deals with bones) aftercare, opioid (medication to reduce moderate to severe pain) dependence, spondylosis (abnormal wear on the neck), and spinal stenosis (narrowing of the spinal area causing pressure on the spinal cord, where spinal nerves leave the spinal column) cervical (neck), lumbar (back), lumbosacral (lower back and pelvic) regions. A review of Patient A's "History and Physical," dated August 16, 2024, indicated, "...associated symptoms include lumbar decompression (reduce pressure) fracture (broken bone) here for management of pain and physical therapy...plan continue her usual pain meds...problem list...opioid (medication to treat pain) dependence with uncomplicated intoxication...Impression...Lumbar compression fracture (occurs when one or more bones in the spine weaken and crumple)...Pain Management..." A review of Patient A's care plan, dated August 14, 2024, indicated, "...has pain r/t (related to) OA (osteoarthritis-tissue at the end of bones wears down), recurrent stenosis L (lumbar) 5 (five) - S (sacral) 1 (one), spondylolisthesis (bones in the back slip and pinch nerves causing severe pain), radiculopathy (a condition that occurs when nerve roots in the spine are damaged or injured), lumbar region (spine)...Interventions. Administer analgesia (pain medicine) as per orders. Give ½ hour before treatments or care...Anticipate the resident's [patient’s] need for pain relief and respond immediately to any complaint of pain...(sign/symptoms) of non-verbal pain...vocalization (grunting, moans, yelling out, silence); mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open...tearing, no focus); face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, ridged, rocking...)...Monitor/record/report to nurse resident [patient] complaints of pain or requests for pain treatment...Observe and report...withdrawal or resistance to care..." A review of Patient A's care plan, dated August 15, 2024, indicated, "...is on pain medication therapy r/t (related to) disease process of RADICULOPATHY, LUMBAR REGION, CHRONIC (long time) PAIN, SPINAL STENOSIS SPONDYLOSIS...Goal...The resident will be free of any discomfort...Interventions...Administer ANALGESIC (pain medicine) medications as ordered by physician..." A review of Patient A's "Order Summary Report," included the following physician's order related to pain, dated August 14, 2024: - "Baclofen (medication to treat spasms) Oral Tablet 10 MG (milligram - unit of measurement) Give 1 (one) tablet by mouth three times a day for Muscle spasm..." - "Diclofenac Sodium (used to treat pain and inflammation) External Gel 1 %...Apply to right Hip topically (onto skin) three time a day for Pain..." - "Diclofenac Sodium External Gel 1 %...Apply to right thigh topically three time a day for Pain...” - "Diclofenac Sodium Tablet Delayed Release 75 MG Give 1 (one) tablet by mouth one time a day for pain..." - "Fentanyl Transdermal Patch (narcotic pain medication) 72 Hour 50 MCG/HR (microgram [unit of measurement]/HR [hour]) Apply 1 (one) patch transdermally (apply on the skin) in the morning every 3 (three) day(s) for pain management..." - "Gabapentin (pain medication) Oral Capsule 300 MG... Give 3 (three) capsule by mouth three times a day for Neuropathy (nerve pain) ..." - "Lidoderm External Patch (used to relieve the pain) ...Apply to lower back topically every 12 hours as needed..." - "Methadone HCl (narcotic pain medication) Oral Tablet 10 MG... Give 1 (one) tablet by mouth two times a day for pain..." and - "Percocet (narcotic pain medication) Oral Tablet 10-325 MG...Give 1 (one) tablet by mouth every 4 (four) hours as needed for Breakthrough pain..." A review of Patient A's "Progress Notes," dated August 14, 2024, at 4:01 p.m., indicated, "...Clinical Admission...Pain issue...New Location: Cervical region (the neck region of the spine). Pain score: 10 (severe pain). Spasm. Frequency: constant...chronic pain related to compression of cervical spine..." A review of Patient A' s "Medication Administration Record (MAR)," dated August 2024, did not indicate pain medication was provided to address Patient A's complaint of pain on August 14, 2024, at 4:01 p.m. Further review of the MAR for August 2024, indicated the following: - Fentanyl transdermal patch was ordered to start August 15, 2024, at 9 a.m., was not administered; - Methadone 10 mg tablet was not administered to Patient A on August 15, 2024, at 9 a.m. and 5 p.m., and on August 16, 2024, at 9 a.m.; - Baclofen tablet 10 mg was not administered on August 14, 2024, at 10 p.m., and on August 15, 2024, at 10 p.m.; - Diclofenac Sodium gel 1% to be applied to right hip and thigh was not administered on August 14, 2024, at 10 p.m., on August 15, 2024, at 6 a.m., 2 p.m., 10 p.m., and on August 16, 2024, at 6 a.m.; - Gabapentin capsule 300 mg (3 capsules) was not administered on August 14, 2024, at 10 p.m., and on August 15, 2024, at 10 p.m.; - Lidoderm external patch 5% was not applied as needed from August 14 to 16, 2024; - Percocet 10/325 mg was administered on August 15, 2024, at 4:10 a.m., and at 9:34 a.m., on August 16, 2024, at 12:51 a.m., and 11:47 a.m., with pain levels of 6 to 8 out of 10. A review of Patient A's "Progress Notes," indicated the following: - August 15, 2024, at 9:05 p.m., indicated, "...Diclofenac Sodium External Gel...awaiting delivery to facility..." - August 15, 2024, at 9:05 p.m., indicated, "...Baclofen...awaiting delivery to facility..." - August 15, 2024, at 9:06 p.m., indicated, "...Gabapentin...awaiting delivery to facility..." - August 16, 2024, at 9:54 a.m., indicated, "Methadone...awaiting pharmacy delivery..." - August 16, 2024, at 10:17 a.m., indicated, "...called pharmacy to follow up on resident [patient] narcotics (medications) with narcotic department stating they spoke with (name of physician) on 08/14/2024 (August 14, 2024)...Per pharmacy (name of physician) stated she would clarify order with facility then call pharmacy back. Pharmacy stated that they have not received a return call from (name of physician). The case manager requested to reach back out to (name of physician)..." - August 16, 2024, at 10:30 a.m.: indicated, "...fentanyl Transdermal Patch...pending pharmacy delivery..." - August 16, 2024, at 10:34 a.m., indicated, "...Late entry for 8/14/24 (August 14, 2024, at 1915 (7:15 p.m.)...Resident [patient] upset her medications were not available upon arrival to facility, expressed wanting to leave facility AMA (Against Medical Advice). This nurse informed resident [patient] her medications would be delivered by our contracted pharmacy, after MD (Medical Doctor) authorized...Medication details were not discussed with resident [patient]..." - August 16, 2024, at 12:45 p.m., indicated, "...Resident [patient] is stating that her pain is 10/10 throughout her entire body...given pain medication per order at 1147 (11:47 a.m.) with results ineffective...n/o (new order) received to send to ER for further evaluation..." - August 16, 2024, at 12:49 p.m., indicated, "...MD notified of resident [patient] complain of back pain, Md (Medical Doctor) did a video call with resident [patient] to see if we can offer an extra Percocet, but resident [patient] stated she wants her pain to be managed. Md notified resident that her Methadone and fentanyl was authorized and will be waiting for delivery...The resident [patient] opted to go back to hospital for pain management..." On August 16, 2024, at 10:45 a.m., a concurrent interview and review of Patient A's record was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated Patient A's Fentanyl patch and Methadone, had not been received from the pharmacy since August 14, 2024. LVN 1 stated Patient A's Percocet was taken out of the E-kit (emergency medication kit). In addition, LVN 1 stated Patient A did not receive any pain medications this morning and had not received Lidocaine 5% patches for her back pain. On August 16, 2024, at 12:10 p.m., during an interview with the DON, the DON stated Patient A's medications (Methadone, Fentanyl patch, and Percocet) had not been received from the pharmacy since the pharmacy needed authorization from the doctor. The DON stated the doctor needed to verify the medications and call the pharmacy to authorize them. She stated she has not heard from the pharmacy or the doctor since August 14, 2024. The DON stated Patient A was in the facility for pain management and rehabilitation therapy, and it was not acceptable for Patient A to have been in the facility for almost 48 hours and not receive her medications and may be experiencing some withdrawal symptoms. On August 16, 2024, at 12:34 p.m., an interview was conducted with Patient A, with the DON present, and the Ombudsman at bedside. Patient A stated she received some Percocet, but she had been in excruciating pain; and she wanted her pain medications. Patient A began crying and stated she was hurting and wanted to end her life. Patient A stated she did not want to feel this way anymore. A review of Patient A's progress notes dated August 16, 2024, at 1:28 p.m., indicated, "...Pt (patient) sent out to ER per MD for c/o (complain of) excruciating 10/10 unmanageable pain..." A review of the facility's policy and procedure titled "Pain Management," dated November 2016, indicated, "...To ensure the assessment and management of the resident's pain to the extent possible when such services are required...staff will help the resident attain or maintain their highest level of well-being while working to prevent or manage the resident's pain to the extent possible...Pain Assessment Flow Sheet...will be initiate for residents who require pain management...Licensed Nurse will administer pain medication as ordered and document...Licensed Nurse will assess the resident for pain and document results on the MAR each shift using the 0-10 pain scale. The shift pain score will indicate the highest pain level that occurred on that shift...the pain has not been relieved with current medication, the Licensed Nurse will notify the attending physician...audit and assess the success of the pain management program..." Based on observation, interview, and record review, it was determined that the facility failed to: 1. Ensure pain medications necessary for the care and treatment of Patient A was made available during admission at the facility; and 2. Ensure pain medications were administered in accordance with the physician order for Patient A who undergone a spinal compression surgery (a procedure that relieves pressure on the spinal cord or nerves) and was admitted to the facility for pain management and physical therapy. As a result of these failures, Patient A experienced severe back pain for two days, from August 14 to August 16, 2024, and was transferred to the GACH on August 16, 2024, for pain management. This violation presented either imminent danger that serious harm would result or a substantial probability that serious physical and emotional harm would result to Patient A.