Other·August 30, 2021

Title 22 §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. F697 §483.25(k) 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. On 5/23/3021 at 4:00 p.m., an unannounced visit was made to the facility to investigate a compliant regarding the quality of care and treatment at the facility and resident neglect. The facility failed to ensure Resident 16, who was admitted on 5/17/2021 at 9 p.m., with a cast to the left ankle, was provided with pain management during the first 12 hours. As a result, Resident 16 had uncontrolled pain to the left ankle from 5/17/2021 to 5/18/2021. A review of Resident 16's Face Sheet indicated the facility admitted the resident on 5/17/2021 from General Acute Care Hospital 1 (GACH 1) with diagnoses including history of muscle weakness and difficulty walking. A review of Resident 16's GACH's Emergency Documentation (ED) dated 5/17/2021, indicated the resident had a cast on his left ankle due to a broken his left ankle had previously broken (fractured) and were still healing. A review of Resident 16's Physician's Telephone Order, dated 5/17/2021 and timed at 9 p.m., indicated, the facility admitted the resident at 9 p.m. A review of Resident 16's Minimum Data Set (MDS – standardized assessment and care-screening tool) dated 5/24/2021, indicated the resident had no memory problem, was able to communicate needs, and required extensive assistance from staff to move in bed, transfer in and out of bed, and in and out of his wheelchair. A review of Resident 16's Physician's Telephone order, dated 5/17/2021, timed at 10:27 p.m., indicated to give Oxycodone-Acetaminophen (combination medication used to relieve pain severe enough to require opioid treatment and when other pain medicines did not work well enough or cannot be tolerated) 5-325 milligrams (mg) one to two tablets, by mouth, every six hours as needed for moderate to severe pain. Not to exceed eight tablets a day, for pain management. A review of Resident 16's Physician's Telephone Order, dated 5/18/2021, timed at 12 a.m., indicated to administer Oxycodone hydrochloride (a drug used to treat moderate to severe pain) 30 mg tablet, by mouth, three times a day, for pain management. On 5/21/2021 at 1:15 p.m., during an interview, Resident 16 stated he needed a lot of help to get up and into the wheelchair because of his left ankle. Resident 16 stated that on the night of his admission to the facility, his left ankle was hurting "terribly" and he "repeatedly asked for pain medication." Resident 16 added, "When they brought me and put me in bed, there was a lot of moving and my ankle hurt with all the moving around, I asked for a pain pill, however, they were all so busy I don't think anyone heard me. I was hurting in the night, I could barely sleep, I started wondering if they could take care of me. They were busy running around, I used my call light, but they didn't come for a while. I don't remember how long, but I still didn't get my pain pill, so it wasn't any help when they came, I gave up until the morning because I thought the doctor, or somebody would come." Resident 16 further started he got the pain pill the next morning. On 5/21/2021 at 1:22 p.m., during an interview, the Regional Quality Manager (RQM) stated Resident 16's medical record did not have any nursing documentation of pain assessments on admission, on 5/17/2021. On 5/21/2021 at 2:43 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated the facility admitted the resident on the night of 5/17/2021, at "around 8:00 or 8:30 p.m." and on that day, the facility had LVNs provided by staffing agency (temporary nurses). LVN 1 stated on that day, the electronic medical record system was not working and she (LVN 1) could not document Resident 16's pain levels or "anything else, so I wrote it all on a piece of paper ... I don't know where the paper went. I don't remember if he was in pain ... He could have been in pain because he had the surgery on his ankle, but I don't remember if he was because we were all so busy ..." On 5/21/2021 at 6:15 p.m., during an interview, LVN 2 stated that on the night of 5/17/2021, "I think we only had three nursing assistants... It was very busy, and I was running around a lot ... that night we definitely needed more help..." On 7/9/2021 at 1:28 p.m., during an interview, Director of Staff Development (DSD) and a concurrent review of Resident 16's Medication Administration Record (MAR) for the month of 5/2021, DSD stated that based on the documentation, the first dose of Oxycodone-Acetaminophen 5-325 was given to Resident 1 on 5/18/2021 at 1 p.m., which 14.5 hours from the ordered date and time (5/17/2021 at 10:27 p.m.). The first dose of Oxycodone HCL 30 mg was administered to Resident 16 on 5/18/2021 at 9 a.m., which was 12 hours from the ordered time (12 a.m.). DSD stated the licensed nurses should have given pain medication timely. DSD stated the Emergency Medication Kit (E-kit) contained eight tablets of Oxycodone-Acetaminophen 5-325. A review of the facility's policy titled, "Physician's Orders," dated 8/21/2021, indicated, "Medication and treatment orders will be transcribed onto the appropriate resident administration record (e.g., medication administration record (MAR) or treatment administration record (TAR). . Orders pertaining to other health disciplines will be transcribed onto that discipline's appropriate communication system." A review of the facility's policy and procedures titled, "Medication - Administration," dated 1/1/2012, the RQM was unable to provide an updated policy, indicated, "Purpose To ensure the accurate administration of medication for residents in the facility ... ii. Medications and treatments will be administered as prescribed ... A review of the facility's policy and procedures titled, "Pain Management" with revised date of November 2012, the RQM was unable to provide an updated policy, indicated, "Facility 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. The Licensed Nurse will administer pain medication as ordered and document medication administered on the Medication Administration Record (MAR)." On 5/23/3021 at 4:00 p.m., an unannounced visit was made to the facility to investigate a compliant regarding the quality of care and treatment at the facility and resident neglect. The facility failed to ensure Resident 16, who was admitted on 5/17/2021 at 9 p.m., with a cast to the left ankle, was provided with pain management during the first 12 hours. As a result, Resident 16 had uncontrolled pain to the left ankle from 5/17/2021 to 5/18/2021. The above violation had a direct or immediate relationship to the health, safety, and security of Resident 1.