Health inspection·July 24, 2024

F697 §483.25(1) Pain Management The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. § 72311. Nursing Service--General. a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (C) Reviewing, evaluating, and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. (G) The facility's inability to obtain or administer, on a prompt and timely basis, drug. §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. (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the patient care policy committee. (c) Each facility shall establish and implement policies and procedures, including but not limited to: (D) Notification of the licensed healthcare practitioner acting within the scope of his or her professional licensure regarding sudden or marked adverse change in a patient's condition. On 6/10/2024 the California Department of Public Health (CDPH) conducted an unannounced recertification survey at the facility. The facility failed to: 1. Ensure Resident 73, who had a Stage 4 pressure ulcer (wound that penetrate all layers of skin exposing muscles, tendons [tissue that unites a muscle with a bone] cartilage {tissue that lines a joint}, and bones caused by prolonged pressure on the skin) to sacrum (tailbone area) area, did not experience unnecessary pain and suffering during pressure ulcer treatment and repositioning. 2. Ensure the Registered Nurse (RN 6) provided Resident 73 with effective pain relief when Resident 73 screamed and moaned loudly during treatment to a Stage 4 sacral pressure ulcer (PU). 3. Ensure the licensed nurses evaluated effectiveness of Tylenol 325 milligrams (mg-unit of measure) two tablets provided Resident 73 for pain relief as ordered prior to start the treatment to a Stage 4 sacral PU. 4. Notify Resident 73's physician MD 1) of Resident 73's pain management with Tylenol was unsuccessful when Resident 73 continued to moan and scream during pressure ulcer treatment on 6/10/2024 and 6/13/2024. 5. Ensure RN 6 evaluated pain characteristics including pain frequency, location, quality, onset, and manner of pain when Resident 73's experienced pain, in accordance with resident's Care Plan titled, "Potential for altered comfort maybe evidenced by grimacing or moaning related to a Stage 4 pressure ulcer to the sacral area, bilateral knee osteoarthritis (degenerative joint disease) and pancreatic mass (tumor that forms in the cells of pancreas) dated 4/20/2023. As a result, Resident 73 experienced severe, unrelieved, and uncontrolled pain manifested by loud screaming and moaning during pressure ulcer treatment and personal care on 6/10/2024 and 6/13/2024. A review of Resident 73's Admission Record indicated Resident 73, a 90 year old female, originally admitted to the facility on 4/19/2023 and readmitted on 10/27/2023 with diagnoses including unspecified dementia (loss of cognitive functioning such as thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), osteoarthritis of both knee (degenerative joint disease), a Stage 4 pressure ulcer to the sacral region, and attention/ concentration deficit. A review of Resident 73's History and Physical (H& P) dated 5/9/2024, indicated Resident 73 was not able to express needs, communicate, not to follow commands and talked in full sentences. Resident 73 had no decisions making capacity. A review of Resident 73's Minimum Data Set ([MDS] standardized assessment and care screening tool) dated 5/1/2024, indicated Resident 73 was dependent on staff for bed mobility, moving from sitting on side of bed to lying flat on bed, toileting hygiene, bathing, dressing, personal hygiene, and oral hygiene. The MDS indicated Resident 73 had a Stage 4 pressure ulcer to sacrum (sacral area). A review of Resident 73's Physician's Order dated 4/20/2024, the Physician order indicated to cleanse sacral wound with Hibiclens (liquid antibacterial cleanser), pat dry, apply Collagen powder to the pressure ulcer base then apply Hydrofera Blue (special dressing type) then cover with Allevyn (dressing) every day (7 a.m.to 3 p.m.) Monday, Wednesday, and Friday. A review of Resident 73's Physician's Order dated 6/10/2024, the Physician's Order indicated the order for Lidocaine spray to apply to the resident's sacral area topically every day for pain management during sacral pressure ulcer treatment. During an observation and concurrent interview on 6/10/2024, at 10:09 a.m., with Resident 73, in Resident 73's room, the resident was observed screaming, groaning, and moaning with facial grimaces (facial expression usually suggesting pain or disgust). Concurrently, during an interview, Resident 73 nodded the head "Yes" and grimaced when asked if she was having pain. During an interview on 6/10/2024, at 10:09 a.m. Resident 62 (Resident 73's roommate) stated Resident 73 was constantly groaning and moaning especially when staff was cleaning or doing personal care. Resident 62 stated staff members were aware of Resident 73's moaning and screaming. During an observation of RN 6 preparation for Resident 73's sacral pressure ulcer treatment on 6/10/2024, at 10:30 a.m., in Resident 73's room, Resident 73's physician (MD 1) entered the resident's room and informed RN 6 he (MD 1) will put an order for Norco (narcotic medication [used to treat moderate to severe pain] pain medication) to administer prior to pressure ulcer treatment as Resident 73 was observed moaning and screaming. RN 6 replied to MD 1 that Resident 73 does not need Norco as Resident 73 will receive Lidocaine spray (topical [applied to the skin] spray) anesthetic applied prior to the pressure ulcer treatment. During an observation of Resident 73's pressure ulcer treatment on 6/10/2024, at 10:32 a.m., in her room, Resident 73 was observed screaming and moaning when RN 6 positioned Resident 73 on her back with head of the bed in a flat position. RN 6 left Resident 73's room and ask another staff member to assist during pressure ulcer treatment. RN 6 came back with the Director of Staff Development (DSD). RN 6 and DSD turned Resident 73 to her right side. Resident 73 continuously moaned and screamed. RN 6 was observed to spray Resident 73's sacral Stage 4 pressure ulcer surrounding area with Lidocaine spray before the start of treatment. Resident 73 started to scream and moan louder when RN 6 was cleaning the reddened surrounding area (peri-wound) of Stage 4 sacral pressure ulcer with Hibiclens and applying Collagen powder (wound dressing that is applied topically) to the pressure ulcer. RN 6 was observed to finish the pressure ulcer treatment despite Resident 73's moaning and screaming. During an interview on 6/10/2024, at 10:45 a.m., and subsequent interview on 6/10/2024, at 11:22 am., RN 6 stated the Lidocaine spray was the only medicine he used to help with Resident 73's pain during pressure ulcer treatment. During a concurrent interview and record review on 6/12/2024 at 9:36 a.m., the DSD stated for residents, who are not able to verbalize pain, the facility was using the facial pain scale tool (a picture with of different facial expressions referencing different pain level to help a resident effectively communicate the severity of their physical pain) to assess pain level. The DSD stated Resident 73 screamed loudly when RN 6 cleansed Resident 73's pressure ulcer with Hibiclens and when the Collagen powder was applied to the resident's Stage 4 sacral pressure ulcer. The DSD stated when Resident 73 screamed loudly during the pressure ulcer treatment, RN 6 should have stopped the treatment, assessed Resident 73 pain level, including the non-verbal cues like facial grimacing, notified the physician, and provide Resident 73 pain medication. The DSD reviewed Resident 73's Medication Administration Record (MAR) and stated Resident 73 received Tylenol 325 mg two tablets on 6/10/2024, at 10:07 a.m., prior to pressure ulcer treatment for pain level 3 out of 10 on a pain scale rating from zero to ten (pain screening tool using numerical value to assess the level of pain ranging from 0 to 3-mild pain, from 4 to 6- moderate pain, and from 7 to 9-severe pain, and 10- the worse pain possible). The DSD stated based on Resident 73 screaming and moaning during sacral pressure ulcer treatment at 10:32 a.m., Tylenol given at 10:07 a.m. was not effective to alleviate Resident 73's pain. The DSD stated Resident 73 experienced "excruciating" (extremely painful, causing intense suffering) pain and discomfort during the pressure ulcer treatment which was "unnecessary pain." The DSD stated RN 6 should have asked the physician for a stronger pain medication after the resident screamed during sacral pressure ulcer treatment on 6/10/2024. During an interview on 6/12/2024, at 3:31 p.m., the Treatment Nurse (TN 1) stated she will ask the charge nurse to give pain medication to the resident before Resident 73's pressure ulcer treatment. TN 1 stated for residents, who could not verbalize pain and its severity, the staff used non-verbal indication of pain like screaming, moaning, or crying, and facial grimace. TN 1 stated Resident 73 screamed and moaned during pressure ulcer treatment, and it was an indication the resident was in "excruciating pain." TN 1 stated Lidocaine spray was used topically and only applied superficially on the skin and would not be enough to help with Resident 73's pain during pressure ulcer treatment. TN 1 stated if Resident 73 screamed and moaned during pressure ulcer treatment RN 6 should have stopped the treatment, call the physician because the Lidocaine spray was not effective in managing Resident 73's pain. TN 1 stated Resident 73 should have been assessed for pain before and during pressure ulcer treatment. TN 1 stated Resident 73's unrelieved pain could affect her health and comfort if her pain was not managed effectively. During an interview and record review on 6/12/2024 at 4:08 p.m., RN 6 stated when Resident 73 screamed from pain during the pressure ulcer treatment, (6/10/2024 and 6/13/2024) he should have stop the treatment and notify Resident 73's MD 1. RN 6 stated on 6/10/2024, MD 1 came to the Resident 73's room and told him (RN 6) about ordering Norco for pain because of the moaning and crying, and confirmed he told MD 1 Resident 73 did not need Norco because the Lidocaine spray was being applied to the pressure ulcer. RN 6 stated Resident 73's family did not want the resident to have any strong pain medication. After reviewing Resident 73's Interdisciplinary Team Meeting ([IDT]-a healthcare team members and resident / family representative collaborate, solve problems, plan, and coordinate care of the resident) Notes and Care Plan, RN 6 confirmed there was no documentation of Resident 73's family not wanting strong pain medication to be given to Resident 73 during pressure ulcer treatment. RN 6 stated Resident 73 was suffering from pain during a sacral pressure ulcer treatment manifested by the resident's screaming and moaning. RN 6 stated Resident 73 continued to suffer from pain because her pain was not addressed and managed during the pressure ulcer treatment on 6/10/2024. RN 6 stated after administration of Tylenol he did not evaluate if the medication was effective in relieving pain prior to proceed with Resident 73's pressure ulcer treatment. During an observation on 6/13/2024, at 10:54 a.m., with TN 1 and a Certified Nursing Assistant (CNA 5) in Resident 73's room, Resident 73 was observed moaning during repositioning. Resident 73 moaned louder as the TN 1 started to clean the surrounding skin area of the sacral pressure ulcer and applying the Collagen powder on the pressure ulcer. TN 1 pauses the pressure ulcer treatment and started reassuring the resident and massaging the resident's skin. TN 1 was observed to resume the treatment when Resident 73 stopped moaning. During an interview on 6/13/2024, at 12:45 p.m. the TN 1 stated Resident 73 moaned during pressure ulcer treatment due to pain. TN 1 stated the resident had dementia and it was hard to tell when the resident was in pain, but the presence of pain during the pressure ulcer treatment should still be addressed by staff by using the resident's facial clues, grimacing, moaning and jerky movement during treatment. During an interview on 6/13/2024, 2:04 p.m., CNA 5 stated every time she would clean and change Resident 73 after a bowel movement, the resident would moan and cry. CNA 5 stated Resident 73 would also moan during pressure ulcer treatment. A review of Resident 73's Care Plan titled, "Potential for altered comfort evidenced by grimacing or moaning related to a Stage 4 pressure ulcer to the sacrum, bilateral knee osteoarthritis and pancreatic mass (tumor that forms in the cells of pancreas),"dated 4/20/2023, the goal for Resident 73 was to be comfortable. The Care Plan's interventions included to identify frequency, location, quality, onset, and manner of expressed pain and administer medication as ordered. A review of Resident 73's Care Plan titled, "Resident has a Stage 4 sacral pressure ulcer on admission," initiated on 10/30/2023 indicated one of the interventions was to assess pain and discomfort at site of the altered skin area. During a concurrent interview and record review of Resident 73's Physician Order on 6/13/2024, at 3:31 p.m. with Director of Nursing (DON), the DON confirmed the physician order for Tylenol 325 mg two tablets for pain relief did not include the pain parameters (measures used to assess the amount, and intensity of pain). However, Resident 73 had an order to monitor the intensity of pain using numerical pain rating scale. The DON stated pain level was not assessed properly and Resident 73's pain was not managed effectively during pressure ulcer treatment. The DON stated Resident 73 should be assessed for pain during and after pressure ulcer treatment. The DON stated if the resident was experiencing pain by screaming and moaning, the pressure ulcer treatment should be stopped, the staff should have assessed the resident for pain, addressed the pain if pain was present, called Resident 73's physician to notify about the presence of pain. The DON stated that Resident 73 had experienced undue suffering, which could have been prevented if the resident was assessed properly for pain management. A review of facility's policy and procedure (P&P) titled "Pain Assessment and Management," undated,