Other·September 10, 2021

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. § 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. The facility failed to effectively manage Resident 1's pain related to cancer by not implementing its policies on Pain - Clinical Protocol and Pain Assessment and Management when: 1. Resident 1’s pain was not relieved with the pain medication ordered as needed (PRN) Norco (a controlled substance with high risk for addiction and dependence; a combination of hydrocodone and acetaminophen, two pain relievers) 2. Licensed nurses did not notify Resident 1’s physician Norco was ineffective and did not request a routine pain medication. 3. Licensed nurses did not accurately assess and document Resident 1's pain level after pain medication was administered, the lack of effectiveness of the pain medication, and the presence of side effects, such as feeling drugged and constipated. As a result, Resident 1 endured constant pain, felt drugged, and ended up becoming constipated leading the resident to leave the facility against medical advice (AMA) on 6/15/2021, four days from admission, because the resident felt he was not helped at the facility. A review of Resident 1's Admission Record (Face Sheet) indicated the facility admitted the resident on 6/11/2021 with diagnoses including bladder cancer (is a common type of cancer that begins in the cells of the bladder. The bladder is a hollow muscular organ in the lower abdomen that stores urine. Signs and symptoms include blood in urine, frequent and painful urination, and back pain), depression (mood disorder that causes a persistent feeling of sadness and loss of interest that can interfere with daily functioning) and chronic (long-term) pain syndrome. A review of Resident 1's Care Plan dated 6/11/2021, developed for the resident's chronic pain related to cancer of the bladder and post-operative discomfort included in the interventions anticipating the resident's need for pain relief and respond immediately to any complaint of pain. A review of Resident 1's Physician's Order dated 6/11/2021, indicated to give acetaminophen tablet 325 milligrams (unit of measure- mg), two tablets by mouth, every six hours PRN for mild pain. A review of Resident 1's Physician Order dated 6/12/2021, indicated to give Norco 10/325 mg, two tablets by mouth, every six hours PRN severe pain. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 6/15/2021, indicated the resident was able to communicate needs, needed limited assistance with bed mobility, dressing, eating, and personal hygiene. A review of Resident 1's Physician Orders indicated there was no order for routine pain medication to control Resident 1's pain. A review of Resident 1's Medication Administration Record (MAR) for the month of 6/2021, indicated Resident 1 was not administered acetaminophen for mild pain. Norco was given as follows: 6/12/2021 at 9:15 p.m. 6/13/2021, at 4:00 p.m. and at 10:00 p.m. 6/14/2021, at 5:30 a.m. and at 9:31 p.m. 6/15/2021, at 10:00 a.m. for pain rated 8 of 10 (8/10, pain rating scale indicating zero as no pain and 10 as the worst pain possible. A review of Resident 1's Progress note dated 6/15/2021 indicated Resident 1 was complaining of lower abdominal and rectal pain secondary to diagnosis of bladder cancer. Resident 1 strongly refused and stated that "I don't want to be drugged up, I need to see my doctor and the pain is unbearable." At 12:45 p.m., Resident left AMA. During an interview on 6/17/2021 at 1 p.m., Certified Nursing Assistant 1 (CNA 1) stated the on 6/15/2021 (the day the resident left the facility), Resident 1 complained of pain around breakfast time. CNA 1 stated she reported it to Licensed Vocational Nurse 1 (LVN 1). During an interview on 6/17/2021 at 12:31 p.m., LVN 1 stated that on the morning of 6/15/2021, Resident 1 was complaining of pain and was offered Norco, but the resident refused because he did not want to be drugged; however, the resident decided to take the Norco later at 10 a.m. LVN 1 stated there was an assessment of pain level prior to giving the resident Norco on 6/15/2021 at 10:00 a.m. but there was no assessment after giving Norco. During an interview on 7/8/2021 at 1:26 p.m., Resident 1 stated on 6/15/2021 before breakfast time, he was having unbearable pain. Resident 1 stated that he refused the Norco because it was making him constipated, and it was not working for him since admission on 6/11/2021. Resident 1 stated the nurses did not offer him alternative medications or routine medication to prevent the pain to become severe. Resident 1 stated he called 911 because he was desperate, but the call was cancelled by a nurse. Resident 1 stated he called 911 because the nurses were ignoring his pain. Resident 1 also stated he left the facility AMA because the facility did not assist him with controlling the pain and Norco was not effective. Resident 1 also stated that he took the Norco on 6/15/2021, at 10:00 a.m. because that was his only option. He was in so much pain and the nurses were not doing anything about his pain, so he decided to finally take it. On 7/13/2021 at 1:56 p.m., during an interview with the Director of Nursing (DON) and concurrent review of Resident 1's MAR for 6/2021, DON stated if the resident had pain, the nurse would assess the level of pain and check the MAR for pain medication to give as needed. If Resident 1 refused the pain medication, the nurse would call the physician for further orders, however, there was no documentation the nurse notified the physician about the resident's refusal, lack of effectiveness, and complaints the medication made him feel drugged and gave him constipation. DON stated there was pain assessment for the morning of 6/15/2021 before Norco was given at 10:00 a.m. but not after the medication was given, to determine effectiveness. A review of facility's policy and procedures titled, "Pain-Clinical Protocol" with revised date of 3/2018, indicated the nursing staff would assess each individual for pain upon admissions to the facility, at the quarterly review, whenever there was a significant change in condition, and when there was onset of new pain or worsening of existing pain. Staff and physician would identify the characteristics of pain such as location, intensity, frequency, pattern, and severity. A review of facility's policy and procedures titled, "Pain Assessment and Management" with revised date of 3/2020, indicated the purpose of the policy was to help staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs that addressed the underlying causes of pain. It also indicated acute pain or significant worsening of chronic pain should be assessed every 30 to 60 minutes after the onset and reassessed as indicated until relief is obtained. The facility failed to effectively manage Resident 1's pain related to cancer by not implementing its policies on Pain - Clinical Protocol and Pain Assessment and Management when: 1. Resident 1’s pain was not relieved with the pain medication ordered as needed (PRN) Norco (a controlled substance with high risk for addiction and dependence; a combination of hydrocodone and acetaminophen, two pain relievers) 2. Licensed nurses did not notify Resident 1’s physician Norco was ineffective and did not request a routine pain medication. 3. Licensed nurses did not accurately assess and document Resident 1's pain level after pain medication was administered, the lack of effectiveness of the pain medication, and the presence of side effects, such as feeling drugged and constipated. As a result, Resident 1 endured constant pain, felt drugged, and ended up becoming constipated leading the resident to leave the facility against medical advice (AMA) on 6/15/2021, four days from admission, because the resident felt he was not helped at the facility. The above violations jointly or separately had a direct or immediate relationship to the health, safety, or security of Resident 1.