Other·February 24, 2022

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.

F760 The facility must ensure that its- §483.45(f)(2) Residents are free of any significant medication errors. 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. On 11/5/2021 the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct a complaint investigation about quality of care. The facility failed to ensure Resident 1, who had diagnoses of aftercare left hip replacement, systemic lupus erythematosus (SLE, an inflammatory disease caused when the immune system attacks its own tissues; SLE can affect the joints, skin, kidneys, blood cells, brain, heart, and lungs) and fibromyalgia (a chronic, long-term illness, that causes all-over muscle pain, joint pain, and fatigue), received pain management and was free from significant medication errors, consistent with professional standards of practice, the facility's policies, and the resident's comprehensive plan of care, by failing to: 1. Administer Resident 1 hydroxychloroquine sulfate (brand name Plaquenil, a medication used in the treatment of arthritis to help relieve inflammation, swelling, stiffness, and joint pain and to help control the symptoms of SLE) 150 milligrams (mg) since admission, 8/22/2021, though 8/28/2021for five days and a total of 10 doses. 2. Administer Resident 1 hydroxychloroquine sulfate 200 mg twice daily as ordered by the covering (on call) physician on 8/28/2021, via cellphone text but misinterpreted by Licensed Vocational Nurse 1 (LVN 1) as giving the medication only on Saturdays and Sundays. Resident 1 missed a total of 86 doses during 43 weekdays between 08/30/2021 and 10/27/2021. 3. Transcribe LVN 1's misinterpreted order to administer Resident 1 hydroxychloroquine sulfate 200 mg twice daily only on Saturdays and Sundays (instead of daily) into the Medication Administration Record (MAR) for the month of 10/2021, for nine weekend days and a total of 18 doses (excluding 10/2/2021). 4. Perform assessment of Resident 1's pain from 08/23/2021 through 08/31/2021 and from 10/1/2021 to 10/31/2021, and document it in the Pain Assessment Flow Sheet every shift as per plan of care and facility's policy. 5. Re-evaluate the pain medication regimen for lack of effectiveness when Resident 1 was complaining of continued pain and was asking for her usual daily hydroxychloroquine sulfate medication between 08/24/2021 to 10/27/2021. As a result, Resident 1 suffered unnecessary continued severe pain and anguish from the time of admission to the facility, on 8/22/2021 until 10/27/2021, when the medication regimen with hydroxychloroquine sulfate was adjusted. On 11/05/2021 at 11:39 a.m., during an interview, Resident 1 stated the nurses were not giving her the hydroxychloroquine sulfate medications for lupus and her body pain became so bad she needed to go to the hospital on 10/2/2021. Resident 1 stated the nurses did not do anything when she complained the hydroxychloroquine sulfate medication should be daily and not just on the weekends and did not call the attending physician to verify what she was telling them. Resident 1 stated that finally about a week ago, the doctor fixed the hydroxychloroquine order. On 11/05/2021 at 1:52 p.m., during an interview, Resident 1 stated she had to suffer so much pain when hydroxychloroquine sulfate was not administered properly. Resident 1 burst into tears stating, "it was unnecessary pain I wouldn't have to go through if the medication was given right." Resident 1 said the nurses and the doctor “messed up her medication orders and took too long to make it right” despite her continued severe pain and her requests to be given her medication daily. A review of Resident 1's Admission Record (Face Sheet) indicated the facility admitted the resident, a 66-year-old female, on 08/22/2021, with diagnoses including aftercare following a left hip joint replacement surgery, systemic lupus erythematosus, chronic obstructive pulmonary disease with exacerbation (COPD - a condition that causes airflow blockage and breathing related problems), major depression (is a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily functioning), and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). A review of Resident 1's Pain Assessment form dated 08/22/2021 indicated the resident had chronic pain on the left hip. The resident's pain intensity was zero out of 10 (0/10, a pain rating scale from zero which indicated no pain to 10 which indicated the worst possible pain). The form indicated movement increased pain and ice packs and as needed (PRN) pain medication relieved the pain. A review of the Physician's Orders for Resident 1, dated 08/22/2021, indicated to: - Perform pain evaluation every shift (three times a day). - Administer Percocet 10-325 mg (brand name, narcotic medication that contains a combination of an opioid pain reliever [oxycodone] and a non-opioid pain reliever [acetaminophen]; it can treat moderate to moderately severe pain), one tablet by mouth every eight hours (scheduled at 6 am, 2 pm and 10 pm) routine for pain management. - Administer Lyrica 150 mg (pregabalin, a nerve pain medication; it can treat nerve and muscle pain, including fibromyalgia; it can also treat seizures) one capsule twice a day for pain management. - Administer MS Contin 30 mg tablet (a brand name for controlled-release morphine sulfate, a narcotic pain reliever used to treat moderate to severe pain) by mouth every twelve hours PRN severe pain (10/10). - Administer Acetaminophen two 500 mg tablets every 8 hours for pain management. - Administer Celebrex (celecoxib) one capsule of 200 mg twice a day for pain management. - Administer hydroxychloroquine sulfate (Plaquenil) 150 milligrams (mg) one tablet by mouth twice a day every weekday (Monday, Tuesday, Wednesday, Thursday, and Friday) and 200 mg twice a day on Saturdays and Sundays for SLE. A review of Resident 1's Care Plan developed on 08/24/2021 for the resident's pain problem, included in the interventions to monitor and record pain characteristics every day and PRN: Quality (sharp, burning); Severity (0 to 10 scale); Anatomical location; Onset (start of the pain); Duration (continuous, intermittent); Aggravating factors; and Reliving factors. A review of the Physician's Order for Resident 1, dated 08/28/2021, indicated to discontinue the hydroxychloroquine sulfate 150 mg tablet and give 200 mg tablet, one tablet by mouth, twice a day every Saturday and Sunday. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated on 08/31/2021 indicated Resident 1 had no memory problems, required limited assistance with one-person physical assist with bed mobility and transfer. Resident 1 needed extensive assistance with dressing and toilet use. Resident 1 was expected to return home soon after recovering from the hip surgery. A review of Resident 1's History and Physical examination completed by the attending physician on 09/01/2021, indicated the resident had the capacity to understand and make decisions. On 11/05/2021 at 4:14 p.m., during an interview with LVN 1 and concurrent record review, LVN 1 stated on 8/28/2021 she communicated by text with the physician covering for Resident 1's attending physician using her cellphone informing him that the pharmacy did not carry the medication in 150 mg. LVN 1 showed the Evaluator the text messages. The physician texted back to give Resident 1 hydroxychloroquine sulfate 200 mg tablet daily. The physician did not discontinue the hydroxychloroquine sulfate scheduled Monday through Friday. LVN 1 acknowledged discontinuing the weekday order of hydroxychloroquine sulfate was a mistake and she misunderstood the physician's order. LVN 1 stated she discontinued hydroxychloroquine sulfate 150 mg during weekdays and wrote the order for hydroxychloroquine sulfate 200 mg on Saturdays and Sundays. A review Resident 1's Nursing Notes and MAR indicated no documentation the resident was assessed for pain every shift as the physician had ordered and as per plan of care from 8/23/2021 to 8/31/2021 and from 10/1/2021 to 10/31/2021. A review of Resident 1's MAR between 08/23/2021 (Monday) and 08/27/2021 (Friday) indicated hydroxychloroquine sulfate 150 mg was not administered for five days and a total of 10 doses. A review of Resident 1's MAR between 08/30/2021 and 10/27/2021 indicated hydroxychloroquine sulfate not administered twice daily during 43 weekdays for a total of 86 doses. A review of the Physician's Orders for Resident 1, dated 09/16/2021, indicated to: - Administer MS Contin 30 mg tablet (a brand name for controlled-release morphine sulfate, a narcotic pain reliever used to treat moderate to severe pain) by mouth every twelve hours PRN severe pain (10/10). - Administer Percocet tablet 10-325 mg one tablet by mouth every eight hours PRN moderate pain (4-6/10). A review of Resident 1's MAR between 10/01/2021 and 10/27/2021 indicated hydroxychloroquine sulfate 150 mg or 200 mg was not administered during the entire month, a total of 31 days and 61 doses, not including one dose on 10/2/2021, when Resident 1 was at General Acute Care Hospital 1 (GACH 1). A review of Resident 1's Nursing Progress Notes, dated 10/02/2021, indicated the resident was sent to GACH 1 Emergency Room (ER) at 9:30 am for evaluation of severe left hip pain. Resident 1 returned to the facility the same day at 10 pm. A review of the Physician's Orders for Resident 1 dated 10/27/2021 indicated to give the resident hydroxychloroquine sulfate 100 mg in the evenings Mondays through Fridays, 200 mg in the mornings Mondays through Fridays, and 200 mg twice a day Saturdays and Sundays. On 11/05/2021 at 4:41 p.m., during an interview, Director of Nursing (DON) stated LVN 1 should have clarified the order before she discontinued the 150 mg of hydroxychloroquine sulfate Monday through Friday. DON validated the medication hydroxychloroquine sulfate was not administered to Resident 1 as ordered, resulting in Resident 1 suffering uncontrolled pain. On 11/05/2021 at 05:02 p.m., during an interview with LVN 1 and concurrent record review, LVN 1 was unable to find documentation of Resident 1's pain assessment every shift and a description of the pain documented in 8/2021. LVN 1 stated that there was an order, but no documentation found to reflect the pain evaluation was assessed every shift. LVN 1 stated that there should be the pain evaluation documented in the MAR as ordered by the physician. A review of Resident 1's MAR indicated Resident 1's pain level when the routine Percocet 10-325 mg was given every eight hours for pain management was as follows: - On 08/24/2021, at 6 am, 2 pm and 10 pm, Resident 1's pain was 10/10. - On 08/25/2021, at 2 pm Resident 1's pain was 10/10. - On 08/26/2021, at 6 am Resident 1's pain was 8/10. - On 08/27/2021, at 6 am Resident 1's pain was 6/10, at 2 pm was 10/10, and at 10 pm was 8/10. - On 08/28/2021, at 6 am and 2 pm Resident 1's pain was 10/10 - On 08/29/2021, at 2 pm Resident 1's pain was 10/10 and at 10 pm was 8/10. - On 08/30/2021, at 6 am, 2 pm, and 10 pm, Resident 1's pain was 10/10. - On 09/01/2021, at 6 am and 2 pm Resident 1's pain was 8/10 and at 10 pm was 6/10. - On 09/02/2021, at 2 pm Resident 1's pain was 6/10. - On 09/03/2021, at 2 pm Resident 1's pain was 8/10 and at 10 pm was 6/10. - On 09/04/2021, at 6 am and 2 pm Resident 1's pain was 8/10. - On 09/05/2021, at 2 pm Resident 1's pain was 8/10. - On 09/06/2021, at 2 pm Resident 1's pain level was 9/10 and at 10 pm was 8/10. - On 09/10/2021, at 2 pm Resident 1's pain was 8/10. - On 09/14/2021, at 2 pm Resident 1's pain was 8/10. On 11/10/2021 at 4:31 p.m., during an interview with DON and concurrent review of Resident 1's MAR, DON stated during 8/2021 and 9/2021, the resident's pain was not managed, and the intensity of the pain was high. DON stated the licensed nurses should have reviewed the pain medications for effectiveness and discuss with the physician to re-evaluate the medication regimen. DON stated the Interdisciplinary Team (IDT - group of healthcare professionals from different disciplines) should have held a meeting to discuss Resident 1's pain management. DON stated Resident 1 reported worsening pain on 10/01/2021, the attending physician was notified and ordered transfer to GACH 1. Resident 1 went to GACH 1 on 10/02/2021 and returned to the facility the same day. DON confirmed the physician's order to monitor and document Resident 1's pain every shift was not carried out and the pain care plan was not followed for the months of 8/2021 and 10/2021. DON stated that the licensed nurses should have assessed pain and documented in MAR because it would be used as a tool to see if the pain medications were effective or not. DON confirmed the lack of Pain Flow Sheet for 9/2021 and 10/2021. DON stated the licensed nurses are to monitor pain and document in the Pain Flow Sheet as per facility's policy. On 12/28/2021 at 11:01 a.m., during a telephone interview, Resident 1's attending physician (Physician 1) stated Resident 1 should have been taking hydroxychloroquine sulfate twice daily for SLE and missing doses aggravated the resident's body pain. On 12/28/2021 at 11:20 a.m., during an interview with LVN 4 and concurrent review of Resident 1's Physician's Orders and the MAR, LVN 4 stated the order, dated 8/28/2021, to administer Resident 1 hydroxychloroquine sulfate 200 mg twice on Saturdays and Sundays was not transcribed to the 10/2021 MAR and that was the reason the licensed nursed did not administer Resident 1 the ordered hydroxychloroquine sulfate. On 12/28/2021 at 1:45 p.m., during the concurrent interview with DON and concurrent review of the MAR, DON stated there was no documentation hydroxychloroquine sulfate was given from 10/1/2021 to 10/26/2021. DON stated Resident 1 was discharged home on 11/27/2021 per the resident's request. A review of the facility's policy and procedure updated 10/2019 titled, "Medication Administration - General Guidelines" indicated medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. A review of the facility's policy and procedures on Pain Management, revised 04/2021, indicated its purpose was to alleviate the resident's pain to a level that is acceptable to the resident while minimizing negative effects on the resident to the extent possible. 1. Pain Assessment A. Upon admission the licensed nurse will assess each resident for pain. B. The licensed nurse will initiate care plan and interventions according to the RAI (Resident Assessment Instrument) guidelines upon admission, annually, significant change of condition, new onset of pain, worsening of pain, new pain medication, pain medication change, and or other. C. The Pain Assessment Flow Sheet will be initiated for residents who require PRN pain medications. D. Th