Health inspection·May 19, 2023

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview, and policy review, the facility failed ensure pain management was provided. This affected two residents (#43 and #56) out of three residents reviewed who had pain managed at the facility. The facility census was 56. Residents Affected - Few Findings Include: 1. Review of the medical record for Resident #44 revealed an admission date 07/16/22. Diagnoses included acute respiratory failure, type two diabetes, spondylosis, sciatica, and Ogilvie syndrome (a disorder affecting the contraction of the bowel). Resident #44 was alert and oriented. Review of the plan of care dated 03/16/23 revealed Resident #44 was at risk for chronic pain related sciatica, spondylosis, and osteoarthritis. Interventions included administering analgesia per orders, identifying and treating, identify previous pain, monitor pain characteristics, notify the physician if interventions were unsuccessful, and provide the resident with reassurance that pain was time limited. Review of the physician order dated 07/16/22 revealed that Resident #44 had an order for Tylenol Extra Strength 500 milligram take two tablets by mouth every eight hours need for pain. Review of the physician order dated 07/18/22 revealed Resident #44 had an order for pain monitoring, to observe for pain. If pain was present treat trying non-pharmacological interventions such as ice packs, warm compress, repositioning, massage, distraction activity prior to medicating if appropriate and check those utilized, if other document in the progress notes every shift. Review of the physician order dated 12/24/22 revealed Resident #44 had an order for Oxycodone (a narcotic pain medication) five milligram tablet take one by mouth every six hours as needed for pain. Discontinued on 04/27/23. Review of the physician order dated 04/27/23 revealed that Resident #44 had an order for Oxycodone five milligram tablet take one by mouth every eight hours as needed for pain. Review of the Medication Administration Record (MAR) dated from 04/01/23 through 05/19/23 revealed Resident #44 had no non-pharmacological interventions prior to the administration of pain medication on 04/15/23, 04/16/23, 04/17/23, 04/18/23, 04/21/23, 04/23/23, 04/28/23, 05/01/23, 05/02/23, 05/03/23, 05/04/23, 05/15/23, and 05/19/23. Interview on 05/19/23 at 4:08 P.M., with the Director of Nursing (DON) who verified the nurse who administered pain medication to Resident #44 had not tried a non-pharmacological pain intervention Page 1 of 3 366376 366376 05/19/2023 Otterbein Middletown 105 Atrium Drive Franklin, OH 45005

F 0697 before administering pain medication to Resident #44. Level of Harm - Minimal harm or potential for actual harm 2. Review of the medical record for Resident #56 revealed an admission date on 04/08/22. Diagnoses included polyneuropathy, pain in the left leg, chronic atrial fibrillation, chronic kidney disease, and osteoporosis. Resident #56 was cognitively intact. Residents Affected - Few Review of the plan of care dated 04/09/23 revealed that Resident #56 was at risk for pain related to decreased range of motion, weakness, decreased activity of daily living, polyneuropathy, left leg pain, and osteoporosis. Interventions included providing pain management each shift, provide rest for involved joints, avoid activities, monitor for ideal body weight, evaluate, and provide adaptive equipment, use range of motion, and refer to therapy. Review of the physician order dated 04/08/22 revealed Resident #56 had an order for pain monitoring, to observe for pain. If pain was present treat trying non-pharmacological interventions such as ice packs, warm compress, repositioning, massage, distraction activity prior to medicating if appropriate and check those utilized, if other document in the progress notes every shift. Review on an order dated 04/15/23 revealed Resident #56 had Oxycodone five mg every four hours as needed for pain. Review of the MAR dated from 04/01/23 through 05/19/23 revealed Resident #56 had no non-pharmacological interventions before pain medication was administered on 04/03/23, 04/08/23, 04/13/23, 04/14/23, 04/17/23, 04/23/23, 04/26/23, 04/28/23, and 05/06/23. Interview on 05/19/23 at 3:34 P.M., with the DON who stated the facility had a lack of documentation. The DON verified the nurse who gave narcotics to Resident #56 had not used non-pharmacological interventions before pain medication was administered. Review of the facility policy titled Pain Management, dated 12/28/21 revealed if the resident identified pain, the nurse would perform a thorough assessment of the resident's pain to differentiate the various types and degree of pain. The assessment will be documented in the medical record. The assessment process will include location of pain, intensity of pain, quality, onset, and aggravating factors. Non-pharmacological forms of interventions will be considered whenever appropriate. The resident, and resident representative when appropriate will be educated regarding this role in managing pain. This deficiency represents non-compliance investigated under Complaint Number OH00142766. 366376 Page 2 of 3 366376 05/19/2023 Otterbein Middletown 105 Atrium Drive Franklin, OH 45005

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on medical record review, staff and resident interview, and policy review, the facility failed to ensure the resident medical record was retained and complete. This affected one resident (#56) out of three resident records reviewed. The facility census was 56 residents. Findings include: Review of the medical record for Resident #56 revealed an admission date on 04/08/22. Diagnoses included polyneuropathy, pain in the left leg, chronic atrial fibrillation, chronic kidney disease, and osteoporosis. Resident #56 was cognitively intact. Review of the plan of care dated 04/09/23 revealed Resident #56 was at risk for pain related to decreased range of motion, weakness, decreased activity of daily living, polyneuropathy, left leg pain, and osteoporosis. Interventions included providing pain management each shift, provide rest for involved joints, avoid activities, monitor for ideal body weight, evaluate, and provide adaptive equipment, use range of motion, and refer to therapy. Review of the physician orders dated 04/15/23 revealed Resident #56 was ordered oxycodone (a narcotic pain medication) five mg every four hours as needed for pain. Review of the medical record revealed there was no narcotic count sheet or pharmacy control sheet for the month of March 2023 or April 2023. Interview on 05/19/23 at 1:38 P.M., Resident #56 said he had not taken any narcotic pain medication over the last couple of months. Interview on 05/19/23 at 2:09 P.M., with the Director of Nursing (DON) who stated she did not have the paper narcotic count sheets for March 2023 and April 2023 for Resident #56. The DON stated she thought another nurse had not filed them properly and had them shredded. The DON stated the process for the narcotic sheets were to be filed in the hard chart of the resident or filed in medical records. The DON stated she could not verify what nurse had taken the narcotic sheet record for Resident #56. Review of the medical record on 05/19/23 at 2:09 P.M. with the DON who verified there was only the May 2023 narcotic count sheet for Resident #56. Review of facility policy titled Medical and Personnel Record Storage, Retention, and Destruction Policy, dated 09/23/2005, revealed the facility shall store, retain, and destroy all records in a manner that was compliant with federal, state, and local laws, regulations, and rules, and that was consistent with this policy and accepted standards of practice. This deficiency represents non-compliance investigated under Complaint Number OH00142766. 366376 Page 3 of 3