Health inspection·May 29, 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 record review, family member interview, and staff interview, the facility failed to assess for pain, administer medication for pain, and document effectiveness of the pain control interventions for one resident. This affected one (#1) of three residents reviewed for pain management. The current census is 81. Residents Affected - Few Findings include: Review of Resident #1's medical record revealed an admission date of 04/10/24, transferred to the hospital on [DATE], returned to the facility on [DATE], and passed at the facility with hospice services on 05/06/24. Diagnoses for Resident #1 included: urinary tract infection, alcoholic cirrhosis of liver, obesity, cellulitis, and altered mental status. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition and was a two-person assist for Activities of Daily (ADL). Review of Resident #1's physician ordered medications revealed on 04/10/24, the resident was ordered to receive Acetaminophen 500 milligrams (mg) every 8 hours for pain and Hydrocodone 5/325 milligrams (mg) 1 tablet every 12 hours as needed for pain. On 04/29/24, the physician ordered Morphine Sulfate oral solution 100 mg/milliliter (ml), 0.25 ml, 0.5 ml, and 1 ml every 1 hour as needed for pain. Review of Resident #1's Medication Administration Record (MAR) dated April 2024 revealed on 04/16/24 Resident #1 was not administered any as needed pain medication. Per the MAR the resident did receive the Acetaminophen 500 mg as prescribed. The pain level was documented on the MAR as an '8' at 8:00 A.M. On 04/16/24, at 4:00 P.M. the pain level was still present at a '5'. On 04/29/24, the resident was not administered any scheduled or as needed pain medications. Further review of the April 2024 MAR revealed on 04/28/24, the nurse documented the pain level as a '7' pain level on the nightshift and on 04/29/24 the nurse documented a '7' pain level on the dayshift. No as needed pain medication was administered per the MAR for the 04/28/24 and 04/29/24 recorded pain assessments. Review of the nursing assessments dated 04/28/24 and 04/29/24 revealed the nurse documented the pain levels as '0'. Review of the hospice progress notes dated 04/28/24 and 04/29/24 revealed no pain level was addressed in the notes. Review of the nursing assessments dated 05/03/24 revealed the nurse documented the pain level as '0'. Review of Resident #1's MAR dated May 2024 revealed one dose of Hydrocodone 5/325 mg orally was Page 1 of 2 365900 365900 05/29/2024 Versailles Rehabilitation and Health Care Center 200 Marker Road Versailles, OH 45380

F 0697 administered on 05/05/24. No other as needed pain medication was documented as administered. Level of Harm - Minimal harm or potential for actual harm Review of Resident #1's narcotic records revealed on 05/05/24, the resident received Morphine Sulfate 0.25 one time, 0.5 ml 3 times, and 1 ml one time for pain. On 05/06/24, the resident received Morphine Sulfate 1 ml one time for pain. No correlating documentation in the MAR, nursing assessments or progress notes were noted as the pain level or assessment of the pain. Residents Affected - Few Interview on 05/29/24 at 2:50 P.M., with family member of Resident #1 revealed the family member observed the resident being agitated and due to his medical condition could not verbalize his pain levels. Per the family member the facility nurses did not provide appropriate pain control by administering the as needed pain medication to Resident #1 prior to his passing. The family member stated the family did request the as needed pain medication but the facility stated the resident has to ask for it and he could not. Interview on 05/29/24 at 2:00 P.M. and 3:00 P.M., with the Director of Nursing (DON) verified the nurses were documenting Resident #1's pain levels but not documenting administering as needed pain medications on 04/28/2024 and 04/29/204. Per the DON, the nurses were providing non-pharmacological interventions, however, not charting the outcomes. The DON verified the resident was receiving the Morphine Sulfate for pain per the hospice orders on 05/05/24 and 05/06/24 prior to his passing. The DON verified the facility nurses were not documenting the effectiveness of the pain medications. Per the DON, the family had requested the last dose of Morphine for the resident and the hospice nurse and primary physician approved the last request for the Morphine. The DON verified the lack of documentation regarding the pain levels and effectiveness of the interventions for Resident #1. This deficiency represents non-compliance found during the investigation for Complaint Number OH00153769. 365900 Page 2 of 2