Other·December 10, 2021

F697 §483.25(k) Pain Management. The facility must ensure that pain management is provided to patients who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the patients’ goals and preferences. T22 72377. Nursing Service – General (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 72377. Nursing Service – General (a) Nursing service shall include, but not be limited to, the following: (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. 72313. Nursing Service – Administration of Medications and Treatments (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed. 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. 72523. Patient Care Policies and Procedures (c) Each facility shall establish and implement policies and procedures, including but not limited to: (2) Nursing services policies and procedures which include: (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 3/18/21 at 8:14 a.m., the California Department of Public Health (Department) conducted an unannounced visit at the facility to investigate a facility reported incident regarding Patient 1’s acute (new) left subcapital (the point where the neck of the femur joins the head) femoral neck fracture (type of hip fracture of the thigh bone [femur] just below the ball of the ball-and-socket hip joint; this type of fracture disconnects the ball from the rest of the femur), quality of care, and patient safety. Patient 1 fell on 2/22/21, was transferred to General Acute Care Hospital (GACH) 1 on 2/22/21 and was readmitted back to the facility on 2/22/21 with new orders for Ativan (anti-anxiety medication) for agitation and inability to relax. Patient 1 was unable to walk, required maximum assist with bed mobility (moving in bed including turning side to side and moving from laying down to sitting up position in bed) and transfers (moving from bed to chair or any other surface), and showed signs and symptoms of pain from 2/22/21 to 3/4/21. The decline in physical functioning and other signs and symptoms of pain were not addressed or reported to Patient 1’s physician (MD 1) until 3/4/21 when MD 1, during his in-person visit, identified Patient 1’s left hip pain and ordered an X-ray (image of the internal composition of a part of the body). The X-ray showed an acute left hip fracture on 3/4/21. The facility failed to notify Patient 1’s physician of a significant change of conditions and provide effective pain management by failing to: 1. Assess, identify, and report Patient 1's decline in physical function from minimal assist (patient requires less than 25 percent [%] assistance to perform the task) to moderate (patient requires around 50% assistance to perform task)/maximum assist (patient requires more than 75% assistance to perform task) during functional mobility and new left lower extremity (LLE) pain as a significant change in condition (COC, clinically significant deviation from a patient's baseline in physical, cognitive [knowledge], behavioral or functional domains that may result in complications without intervention) after Patient 1’s fall on 2/22/21, and continued Physical therapy (PT) and Occupational therapy (OT) from 2/23/21 up to 3/4/21 (9 days). 2. Implement Patient 1’s care plan for “ADL (activities of daily living) Functional/Rehabilitation Potential" to monitor for any decline in ADL function and inform the patient’s physician. 3. Implement the facility’s policy and procedures titled, “Changes in Patient Condition,” for facility staff to notify the patient’s attending physician where there is a significant change in the patient’s physical, mental, or psychosocial status. 4. Assess and administer pain medication according to Patient 1’s verbal and non-verbal indicators of pain such as grimacing, wincing, and restlessness from 2/22/21 to 3/5/21. 5. Administer pain medication in accordance with Patient 1’s physician's orders and obtain new physicians’ orders for Patient 1’s assessed pain levels. Patient 1 had a physician order for acetaminophen (pain medication) 325 milligrams (mg) two tablets by mouth twice daily as needed for mild pain. There was no other pain medication ordered and available as needed for Patient 1’s moderate to severe pain until 3/5/21. After a new pain medication was ordered for moderate to severe pain on 3/5/21, facility did not administer the appropriate pain medication as ordered according to the degree of Patient 1’s assessed pain. Patient 1 did not receive the appropriate pain medication for signs of Patient 1’s assessed pain levels on 2/22/21, 2/23/21, 2/25/21, 2/27/21, 3/3/21, 3/4/21, and 3/5/21. 6. Implement Patient 1’s current care plan interventions to assess non-verbal signs of pain as manifested by facial expressions, protective body movement, identifying origin of pain and consult the MD 1 if measures failed to provide adequate pain relief. 7. Implement the facility's policy and procedure on "Pain Management," by not notifying MD 1, not recognizing the presence of Patient 1’s pain through verbal and non-verbal behaviors, and not using the pain rating scale to determine the appropriate type of pain medication. Patient 1 did not receive any pain interventions from 2/22/21 (after the fall) up to 3/4/21 when the patient demonstrated signs of pain on 2/22/21, 2/23/21, 2/25/21, 2/27/21, 3/3/21 and 3/4/21. Patient 1 did not receive the appropriate pain medication according to the patient’s assessed levels of pain on 3/5/21. As a result, Patient 1 experienced unrelieved pain manifested by facial grimacing, complaints of pain during PT and OT, a decline in physical function for bed mobility and transfers from minimum assist to maximum/moderate assist, inability to walk, and refusal to get out of bed for 11 days (after the fall incident on 2/22/21 up to 3/5/21). This deficient practice also resulted in the delay of Patient 1’s diagnosis and treatment of an acute left hip fracture. Patient 1 was transferred to GACH 2 on 3/5/21 and stayed for four days, received pain management for severe pain with narcotic medication, received a surgical consult for surgery of the left hip, received physical therapy and occupational therapy treatment, and Patient 1’s lower left extremity was placed on a non-weight bearing status (inability to bear weight on the extremity) A review of Patient 1's Face Sheet indicated Patient 1, a 99-year-old male, was initially admitted to the facility on 2/19/21 and readmitted back to the facility on 2/22/21 with diagnoses including but not limited to urinary tract infection (UTI, an infection in any part of the urinary system), benign prostatic hyperplasia (BPH, Age-associated prostate gland enlargement that can cause urination difficulty), and heart failure (condition in which the heart has difficulty pumping enough blood to keep up with demands of the body). A review of Patient 1's Minimum Data Set (MDS, a standardized assessment and care-screening tool) admission assessment, dated 2/25/21, indicated Patient 1 had short and long-term memory problems, had moderately impaired cognitive skills for daily decision making, did not exhibit any depressed mood behaviors, and did not have any functional limitations in range of motion (ROM, full movement potential of a joint) to both arms and both legs. The MDS indicated Patient 1 required extensive one-person assistance with bed mobility and two-person extensive assistance for transferring. A review of Patient 1’s physician's order, dated 2/19/21, indicated to administer acetaminophen 325 mg two tablets by mouth twice daily, as needed for mild pain. A review of Patient 1’s physician's order, dated 2/19/21, indicated to monitor Patient 1 for pain every shift with the use of pain rating scale: “0 is no pain, 2 is mild pain, 4 to 6 is moderate pain, 8 to 10 is severe pain.” The physician’s order indicated the behavior indicators of pain to monitor included crying, whining, moaning, or groaning, grimaces, winces, bracing, guarding, rubbing/massaging, restlessness, clutching or holding. A review of Review of Patient 1’s PT Evaluation and Plan of Treatment, dated 2/20/21, indicated Patient 1’s left lower extremity (leg) ROM was within functional limits (WFL, a person’s ability is outside of the normal range, but it is sufficient for ADLs) with zero out of 10 (no pain) pain at rest. The PT Evaluation indicated Patient 1’s bed mobility, transfers, and gait (ambulation or ability to walk) was evaluated at minimum assist. The PT evaluation also indicated Patient 1 was able to walk 50 feet with minimum assist using a front wheeled walker (a walking frame used as a tool for persons who need additional support to maintain balance or stability while walking). A review of Patient 1’s Progress notes titled, "SBAR (Situation, Background, Assessment, Recommendation, a technique that can be used to facilitate prompt and appropriate communication) Communication Tool and Progress Note,” dated 2/22/21, timed at 12:30 am, indicated Patient 1’s bed alarm was heard. Upon checking on the patient, Patient 1 was found lying on the floor, on his left side by the right side of the bed. The SBAR Progress Note indicated Patient 1 sustained skin tears on the left parietal (left side of scalp above ear) area and the left elbow. The SBAR Progress Note indicated Patient 1’s body assessment was completed with no other injuries noted and Patient 1 was able to move all extremities without any limitation and without any complaints of pain. The SBAR Progress Note indicated Patient 1’s MD 1 was notified at 12:56 am. A review of Patient 1’s physician orders, dated 2/22/21, indicated to transfer Patient 1 to the GACH 1 Emergency Department (ED) for further evaluation after a fall, and increasing confusion, agitation, and restlessness. A review of the GACH 1 ED Physician Notes dated, 2/22/21, indicated Patient 1 presented to GACH 1 for left sided forehead laceration due to a fall from bed, the same morning (2/22/21). The GACH 1 ED Physician Notes indicated Patient 1 complained of pain to the left hip especially with movement and a head laceration after a fall. The GACH 1 ED Physician Notes indicated Patient 1 fell off the bed onto the left side with history taken from Patient 1’s family member (FM 1). The GACH 1 ED Physician Notes indicated Patient 1 could not tolerate and refused the computed tomography scan (CT scan, combines a series of X-ray images taken from different angles around the body). The GACH 1 ED Physician Notes indicated Patient 1 was discharged back to the facility the same day (2/22/21). A review of a facility document titled “Incident/Accident Post Review,” recorded on 2/24/21, timed at 11:40 am, electronically signed by the facility’s interdisciplinary team (IDT, a group of healthcare providers from different fields who work together or toward the same goal to provide the best care or best outcome for a patient) indicated the IDT met to discuss the plan of care for Patient 1 due to the fall that happened on 2/22/21 at 12:30 am. The Incident/Accident Post Review indicated the facility would continue to monitor for any change in condition. A review of a facility document titled, “Patient Progress Notes,” dated 2/22/21, timed at 2:25 pm, indicated Registered Nurse (RN) 1’s notes indicating Patient 1 returned from the GACH 1 ED, still confused, and restless. RN 1’s Patient Progress Notes indicated speaking to MD 1 and received an order to administer Ativan (anti-anxiety medication) tablet 0.5 mg orally every six hours to Patient 1, as needed for agitation manifested by inability to relax. A review of Patient 1's care plan titled, "ADL (activities of daily living) Functional/Rehabilitation Potential," dated 2/22/21, indicated to "monitor for any decline in ADL (activities of daily living) function and inform MD (attending physician) and responsible party." A review of Patient 1’s care plan titled, “Pain,” dated 2/22/21, indicated, “Staff assessment indicated pain or possible pain as manifested by non-verbal sounds, vocal complaints of pain, facial expression, protective body movements or posture.” The care plan approaches included, observing the patient for non-verbal indication of pain and identifying origin of pain, administering pain medication as ordered: acetaminophen [over the counter; OTC] tablet: 325 mg; amount: 650 mg, by mouth twice daily as needed for mild pain and evaluate effectiveness and to consult MD 1, if above measures fail to provide adequate pain relief. A review of Patient 1’s OT Evaluation and Plan of Treatment, dated 2/23/21, indicated the patient had four (moderate pain) out of 10 pain in the left leg with movement. The OT evaluation indicated Patient 1 verbalized the pain level and the pain limited Patient 1's functional activities. A review of Patient 1’s PT Treatment Encounter Notes indicated the following information: a. On 2/23/21, Patient 1 required maximum assist with bed mobility and transfers and did not ambulate (walk). Patient 1 exhibited grimacing upon LLE range of motion and LLE movement at four out of 10 on a facial pain scale (scale using facial expressions to determine level of pain, zero is no pain, 10 is excruciating pain). b. On 2/24/21, Patient 1 required maximum assist with bed mobility and transfers and did not ambulate. c. On 2/25/21, Patient 1 “complained of pain on the left thigh, charge nurse was notified for pain management.” d. On 2/26/21, Patient 1 required moderate assist with bed mobility, maximum assist with transfers and did not ambulate. e. On 2/27/21, Patient 1 “States seven out of 10 pain on LLE with weight bearing [putting weight on the extremity]." The Treatment Encounter Notes indicated Patient 1 required maximum assist with transfers and no ambulation occurred. f. On 3/1/21, Patient 1 required maximum assistance to get up from supine (lying position in bed) to sitting position by the edge of bed and no ambulation occurred. g. On 3/3/21, Patient 1’s bed mobility was at moderate assistance, pre