Health inspection·June 8, 2021

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 medical record review, staff interview, resident interview and review of facility policy the facility failed to ensure a physician ordered appointment for an orthopedic consult for Resident #20 was scheduled timely to address her chronic pain and failed to assess the effectiveness of her pain medications. This affected one resident (Resident #20) of 12 residents reviewed for pain management. The facility census was 41. Residents Affected - Few Findings include: Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] with diagnoses of osteoarthritis of the right shoulder, chronic pain, osteoporosis, pain in the joints of the left hand, trigger finger left index finger, and pain in the right and left knee. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #20 had intact cognition, required supervision for all activities of daily living (ADLs), had diagnoses of osteoarthritis, right shoulder pain, chronic pain, and osteoporosis. She received scheduled pain medications, had pain present, the pain was almost constant and the resident rated the pain at a level of six (on a scale from one to 10 with 10 being the worst pain), and received opioids for seven days. Review of the June 2021 physicians orders revealed Resident #20 had orders for, hydrocodone-acetaminophen (narcotic pain medication) 10/325 milligrams (mg) four times daily for chronic pain dated 02/21/20, Aspercreme (analgesic cream) with lidocaine four percent to the left hip every morning for pain dated 07/23/20, Aspercreme with Lidocaine patch four percent topically to the lower back every morning for pain dated 07/24/20, and acetaminophen 500 mg two tablets twice daily for osteoarthritis, (named facility) Orthopedic consult for bilateral knee pain dated 02/25/21, and Aspercreme with lidocaine four percent to the right hip topically every six hours as needed for pain dated 05/22/21. Review of the June 2021 vital signs, pain levels record revealed Resident #20's pain level was consistently rated at a level of six to eight. Review of the May 2021 vital signs, pain levels record revealed Resident #20's pain level was consistently rated at a level of five to eight. Review of the April 2021 vital signs, pain levels record revealed Resident #20's pain level was rated anywhere from a level three to a level 10. Review of the May and June 2021 Medications Administration Records revealed Resident #20 was Page 1 of 4 365579 365579 06/08/2021 Carroll Healthcare Center Inc 648 Longhorn Street Carrollton, OH 44615

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few administered hydrocodone 10/325 mg four times daily and acetaminophen 500 mg twice daily with the pain level before administration documented however, there was no documentation of how effective the medication was for relief of pain. Review of the physician's progress notes dated 02/25/21 revealed Resident #20 had left hip, back and bilateral knee pain secondary to osteoarthritis, x-rays of the left hip, lumbar spine and bilateral knees showed no acute findings but the resident continues to utilize hydrocodone 10/325 mg four times daily and acetaminophen 500 mg two tablet twice daily and the nursing staff reports these are effective. The plan was to get an orthopedic consult. Review of the plan of care dated 02/26/21 revealed Resident #20 was at risk for pain related to chronic kidney disease, chronic pain, osteoporosis, and osteoarthritis in bilateral knees. Interventions included notify the physician promptly if interventions were ineffective for pain relief, pain assessment quarterly and as needed, monitor for side effects pf pain medications, call light within reach and answer timely, assist and reposition as needed for comfort, medications as ordered, encourage activity attendance to keep busy, and arrange skilled therapy as indicated with physician's order. Review of the nurse practitioner progress notes dated 03/01/21 revealed the visit was due to family concerns of back pain and requesting a consultation with a specific physician at (a named hospital) Pain Management. Review of the facility LTC charting dated 03/18/21, 03/19/21, and 03/23/21 revealed Resident #20 had pain, almost constantly, it did not affect her sleep, did not affect her day-to day activities and she had a pain level of eight. The resident indicated the non-pharmacological interventions effective in alleviating pain were one on one, repositioning and Lidocaine patch and crème to back and left hip. Review of the facility LTC charting dated 03/20/21, revealed Resident #20 had pain, almost constantly, it did not affect her sleep, did not affect her day-to day activities and she had a pain level of five. The resident indicated the non-pharmacological interventions effective in alleviating pain were one on one, repositioning and Lidocaine patch and crème to back and left hip. Review of the facility LTC charting dated 03/21/21 and 03/22/21 revealed Resident #20 had pain, almost constantly, it did not affect her sleep, did not affect her day-to-day activities and she had a pain level of four. The resident indicated the non-pharmacological interventions effective in alleviating pain were one on one, repositioning and Lidocaine patch and crème to back and left hip. Review of the facility LTC charting dated 03/24/21, 04/03/21, and 04/04/21 revealed Resident #20 had pain, almost constantly, it did not affect her sleep, did not affect her day-to day activities and she had a pain level of six. The resident indicated the non-pharmacological interventions effective in alleviating pain were one on one, repositioning and Lidocaine patch and crème to back and left hip. Review of the facility LTC charting dated 04/01/21, 04/02/21, 04/05/21, and 04/07/21 revealed Resident #20 had pain, almost constantly, it did not affect her sleep, did not affect her day-to day activities and she had a pain level of seven. The resident indicated the non-pharmacological interventions effective in alleviating pain were one on one, repositioning and Lidocaine patch and crème to back and left hip. 365579 Page 2 of 4 365579 06/08/2021 Carroll Healthcare Center Inc 648 Longhorn Street Carrollton, OH 44615

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the 04/06/21 pain assessment revealed the resident was in constant pain, the pain did not affect her functioning and she rated her pain level at a six. Interview on 06/07/21 at 2:05 P.M. revealed Resident #20 indicated she was in constant pain in her back, hips, and legs. She indicated she had an appointment with the orthopedic doctor but someone came in her room and took the paper down with the appointment on it that was hanging up in her room and never put a new one up so she had no idea what was going on. She indicated her pain would ease up some when she first took her pain medication, or the nurse applied the cream, but it was not long before the pain was back. She indicated she was never without pain and she wanted something done about it. She indicated it did not affect her daily activities, but it was painful to walk sometimes because her hips hurt so bad. Interview on 06/07/21 at 2:20 P.M. with Licensed Practical Nurse (LPN) #16, who was responsible to set up resident appointments and transportation, indicated she had an appointment set for Resident #20 on 07/22/21 for (named facility) Orthopedics but nothing set up for 05/06/21. Interview on 06/07/21 at 2:38 P.M. revealed Registered Nurse (RN) #15 indicated she documented the resident's pain assessment on paper. She stated she would ask the residents the questions and that was how she determined how to code the MDS. She indicated she kept all the paper assessments in a separate file in her office. Interview on 06/07/21 at 3:20 P.M. revealed the Administrator indicated the facility was attempting to accommodate the readmission of another resident who required dialysis and need the transport van for her dialysis appointments. He indicated they had canceled and rescheduled some other residents' appointments and Resident #20 had been one of the residents who had been rescheduled. He indicated he had called the daughter of Resident #20 to ask her to transport the resident to the 05/06/21 appointment however, she was unable to do so. He indicated they had to reschedule Resident #20's orthopedic consultation appointment from 05/06/21 to 07/22/21. He verified her appointment had been ordered on 02/25/21 and was not able to be scheduled until 05/06/21, and then they canceled and rescheduled the appointment for 07/22/21 causing the resident to wait almost five months to see the orthopedic physician. He stated at the time they rescheduled the appointment he was unaware it had taken two months to get her the first appointment with the orthopedic physician. Interview on 06/07/21 at 4:18 P.M. revealed the Administrator indicated at the time Resident #20's appointment was rescheduled they were unable to use another transport company because the transport company was not testing their drivers for COVID, they refused to allow the facility to test their drivers, and per Centers for Medicare and Medicaid Services (CMS) guidance the facility was responsible for the well-being of all their residents. He indicated he did not feel it was safe for the resident to be transported by anyone but the facility van. He verified the resident had been vaccinated for COVID-19 in January 2021. Interview on 06/07/21 at 5:00 P.M. revealed the Administrator indicated the resident's primary care physician was starting to do pain management in the facility by administrating injections however, Resident #20 had not received any injection yet. Interview on 06/08/21 9:42 A.M. revealed RN #15 verified there was no evidence of documentation of the effectiveness of pain medication for Resident #20, only her pain lever prior to administration. Review of the facility policy, Pain Assessment and Management, dated 03/15 revealed the purpose was 365579 Page 3 of 4 365579 06/08/2021 Carroll Healthcare Center Inc 648 Longhorn Street Carrollton, OH 44615

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to help staff identify pain in the resident and to develop interventions that were consistent with the resident's goals and needs and that address the underlying causes of pain. If pain had not been adequately controlled, the multidisciplinary team, including the physician should reconsider approaches and make adjustments as indicated. Document the resident's reported level of pain with adequate detail, enough information to gauge the status of pain and the effectiveness of the interventions for pain as necessary and in accordance with the pain management program. 365579 Page 4 of 4