Health inspection·August 23, 2024

42CFR §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 7/8/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct its annual Recertification Survey. The facility failed to: 1. Ensure Resident 79, who was at risk for pain and distress (state of extreme sorrow, suffering, or pain) related to chronic pain syndrome (persistent pain that lasts weeks to years) received care and services in accordance with professional standards of practice by failing to ensure Resident 79's unrelieved pain was managed. 2. Ensure nonpharmacological interventions (science-based, non-invasive healthcare interventions that are not primarily based on medication) were provided by the licensed nurses prior to administering as needed (prn) opioid medication (powerful pain-reducing medications) for Residents 278, 38, and 41. As a result, this caused Resident 79 to experience continued unrelieved moderate pain (pain rated at four [4] to six [6] out of 10, on a pain scale from zero [0] to 10, where 10 is the worst possible pain) on 7/9/2024 from 10:45 a.m. until 3:06 p.m.; and had the potential to place Residents 278, 38, and 41 at increased risk of experiencing adverse side effects from opioid pain medication, such as sedation (a state of calmness, relaxation, or sleepiness caused by certain medications), dizziness (feeling faint, woozy, weak or unsteady), nausea (a feeling of discomfort or sickness in the stomach that can lead to an urge to vomit), vomiting, constipation (unable to have a bowel [stool] movement), physical dependence (a condition in which a person takes a drug over time, and unpleasant physical symptoms occur if the drug is suddenly stopped or taken in smaller doses), tolerance, and respiratory depression (a breathing disorder that occurs when someone breathes too slowly or shallowly). 1. During a review of Resident 79's Admission Record indicated that Resident 79 was originally admitted to the facility on 3/27/2024 and readmitted on 7/8/2024 with diagnoses that included chronic pain syndrome (persistent pain that lasts weeks to years). During a review of Resident 79's History and Physical (H&P), dated 4/6/2024, indicated that Resident 79 had the capacity to understand and make decisions. During a review of Resident 79's Minimum Data Set (MDS - a standardized resident assessment and care screening tool) assessment dated 4/8/2024, indicated that Resident 79's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. During a review of Resident 79's Care Plan for "at risk for pain" dated 7/9/2024 indicated to anticipate Resident 79's need for pain relief, and to respond immediately to any complaints of pain. During a review of Resident 79's Physician Orders, indicated an order for Oxycodone Hydrochloride (Oxycodone HCl - a medication used to treat moderate to severe pain) oral tablet 10 milligrams (mg- unit of measure), to give one (1) tablet by mouth every six (6) hours as needed for severe pain (pain rated at seven [7] to 10, on a pain scale from zero [0] to 10, where 10 is the worst possible pain); with a start date of 7/8/2024. During a review of Resident 79's Medication Administration Record (MAR- the report that serves as a legal record of the medications administered to a resident of a facility by a health care professional) for 7/2024 indicated that Licensed Vocational Nurse 5 (LVN 5) administered a dose of Oxycodone HCL 10 mg to Resident 79 on 7/9/2024 at 9:52 a.m. for pain rated at 10. During a concurrent observation and interview on 7/9/2024 at 2:33 p.m., with Resident 79, observed Resident 79 grimacing (facial expression of pain) while in bed, inside Resident 79's room. Resident 79 stated that she (Resident 79) was experiencing severe pain rated at 10 in Resident 79's back and stomach area. Resident 79 stated that LVN 5 provided Resident 79 with oxycodone HCl at around 9:52 a.m., but that Resident 79's pain remained unrelieved. Resident 79 stated that she (Resident 79) informed LVN 5 at around 12:00 p.m. of the on-going unrelieved pain that Resident 79 was experiencing. Resident 79 stated that she (Resident 79) was informed by LVN 5 that there was "nothing else" that could be done or given to Resident 79. Resident 79 stated that she (Resident 79) felt that she (Resident 79) would benefit from additional pain medications. Resident 79 verbalized that she (Resident 79) was frustrated about being left in pain with nothing being done. During a concurrent observation and interview on 7/9/2024 at 2:36 p.m., with LVN 5 and Resident 79, observed Resident 79 inside Resident 79's room crying. Resident 79 stated that she was experiencing pain and continued to cry. During an interview on 7/9/2024 at 2:38 p.m. with LVN 5, LVN 5 stated that Resident 79 was administered Oxycodone HCl 10 mg earlier in the morning (9:52 a.m.). LVN 5 stated that LVN 5 did not reassess the effectiveness of Resident 79's Oxycodone HCL 10mg that was administered early that morning (7/9/2024 at 9:52 a.m.). LVN 5 further stated that pain reassessments are to be done 30 minutes to one [1] hour after a pain medication is given. When LVN 5 was asked if there was anything else being done related to Resident 79's unrelieved pain, LVN 5 stated that LVN 5 informed Registered Nurse 3 (RN 3) of Resident 79's unrelieved pain (time not specified) so that RN 3 can inform Resident 79's physician. During an interview on 7/10/2024 at 10:15 a.m. with RN 3, RN 3 stated that LVN 5 did not inform RN 3 of Resident 79's unrelieved pain on 7/9/2024. RN 3 stated that it was not until 7/9/2024 sometime after 2:38 p.m. that RN 3 discovered that Resident 79 was experiencing unrelieved pain. RN 3 stated that after discovering that Resident 79 was experiencing unrelieved pain, RN 3 called Resident 79's physician and obtained an order for additional pain medication of Morphine Sulfate (a medication used to help relieve moderate to severe pain). RN 3 further stated, unrelieved pain can negatively affect the resident causing the resident to cry, be upset, feel depressed (feel sad), isolate (to separate) oneself and delay healing. During a review of Resident 79's Physician Orders, indicated an order for Morphine Sulfate 15 mg tablet, give one (1) tablet by mouth one time for severe pain, with a start date and time of 7/9/2024 at 2:58 p.m. During a review of Resident 79's MAR dated 7/2024 indicated that Resident 79 was administered Morphine Sulfate 15 mg tablet on 7/9/2024 at 3:06 p.m. During a review of Resident 79's progress notes dated 7/9/2024 at 4:01 p.m., the note indicated that Resident 79 was asleep in bed. The note further indicated that no signs and symptoms of distress were noted. During a follow up interview on 7/11/2024 at 2:00 p.m., with LVN 5, LVN 5 stated that on 7/9/2024 at 10:52 a.m., LVN 5 did reassessed Resident 79's pain level after the administration of Oxycodone HCl and noted that Resident 79 had unrelieved pain of six (6) out of 10. LVN 5 stated that LVN 5 should have documented the reassessment of Resident 79's pain at 10:45 a.m. rather than documenting a late entry of Resident 79's reassessment on 7/9/2024 at 2:53 p.m. LVN 5 restated that LVN 5 informed RN 3 to call Resident 79's physician to obtain additional orders to help manage Resident 79's pain. During a review of Resident 79's Medication Administration Note with an effective date of 7/9/2024 and a created date of 7/9/2024 at 2:53 p.m., the note indicated that the administered medication of Oxycodone HCl 10 mg by LVN 5 to Resident 79 on 7/9/2024 at 9:52 a.m. was ineffective. The note further indicated that Resident 79 was experiencing unrelieved pain of six out of 10. During an interview on 7/11/2024 at 2:53 p.m. with the Director of Nursing (DON), the DON stated that it is important to control a resident's pain to ensure that residents are comfortable and pain-free. The DON stated pain reassessments should be completed within an hour of pain medication administration to check for efficacy. The DON stated, for Resident 79's ineffective pain medication of Oxycodone HCL 10mg administered on 7/9/2024 at 9:52 a.m., LVN 5 should have notified Resident 79's physician immediately to obtain additional orders to help manage Resident 79's unrelieved pain. The DON stated, severe pain is harmful because it can affect a resident's emotional state (the state of a person's emotions in a particular time), level of cooperation, vital signs (measurements of the body's most basic functions), and ability to heal. A review of the facility's policy and procedure (P&P) titled, "Pain Assessment and Management" last reviewed 4/23/2024, indicated that residents are to receive treatment and care in accordance with professional standards of practice ... related to pain management. The policy further indicated that the facility is to monitor the effectiveness of interventions and modify approaches as necessary. The policy states that if pain is not adequately controlled, the facility shall reconsider approaches and make adjustments as indicated. 2.a. A review of Resident 38's Admission Record indicated the facility admitted the resident on 1/9/2024 with diagnoses including pressure ulcer (a skin injury caused by constant pressure on an area of the body for a long period of time) of the sacral region (the triangular-shaped bone at the base of the spine). A review of Resident 38's MDS dated 4/16/2024, indicated the resident had intact cognition and required setup or clean-up assistance from staff for most activities of daily living (ADLs - the basic personal care tasks that people need to do on their own to live independently). A review of Resident 38's care plan for risk for pain related to disease process, initiated on 1/9/2024, indicated the goal that the resident will not have discomfort related to side effects of analgesia (the inability to feel pain) through the review date. Among some of the interventions listed was to keep the resident in a comfortable position. On 7/10/2024 at 8:24 a.m., during a concurrent interview and record review, reviewed Resident 38's physician's orders with Registered Nurse 5 (RN 5). RN 5 stated Resident 38 had a physician's order for Percocet (a type of opioid medication to treat pain) 5-325 milligrams (mg - unit of measurement), give one tablet by mouth every six (6) hours as needed for pain management. Reviewed the resident's 6/2024 MAR with RN 5. RN 5 stated the resident received Percocet 5-325 mg every day on multiple shifts. When asked what nonpharmacological interventions were provided to the resident, RN 5 stated there was no documentation indicating the licensed nurses provided nonpharmacological interventions to Resident 38 prior to administering Percocet 5-325 mg. Reviewed Resident 38's 7/2024 MAR with RN 5. RN 5 stated Resident 38 received Percocet 5-325 mg every day on multiple shifts. When asked what nonpharmacological interventions were provided to Resident 38, RN 5 stated there was no documentation indicating the licensed nurses provided nonpharmacological interventions to Resident 38 prior to administering the Percocet 5-325mg. RN 5 stated licensed nurses should be attempting nonpharmacological interventions prior to administering prn pain medication because it's possible that the resident may not need the medication. RN 5 stated the potential side effects the resident can experience from receiving too much opioid pain medication include an overdose or an increased risk of sedation. On 7/11/2024 at 10:12 a.m., during an interview, the DON stated it is important for nurses to attempt nonpharmacological interventions prior to administering prn opioid medications because it is possible the resident may not need the medication. The DON stated that opioid medications increased the risk for constipation, sedation, and falls. 2.b. A review of Resident 41's Admission Record indicated the facility originally admitted the resident on 10/2/2023 and readmitted Resident 4 on 10/31/2023 with diagnoses including stage four (4) pressure ulcer of the sacral region. A review of Resident 41's MDS, dated 4/4/2024, indicated the resident had moderately impaired cognition and was mostly dependent on staff for ADLs. The MDS also indicated the resident received prn opioid pain medications. A review of Resident 41's care plan for risk of pain, initiated on 11/6/2023, indicated a goal that Resident 41 will not have discomfort related to side effects of analgesia. Among some of the interventions listed included to keep Resident 41 in a comfortable position. On 7/10/2024 at 8:37 a.m., during a concurrent interview and record review, reviewed Resident 41's physician's orders with RN 5. RN 5 stated Resident 41 had a physician's order for oxycodone hydrochloride (Oxycodone HCl- a type of opioid medication used to treat pain) five (5) mg, give one tablet by mouth ever four (4) hours as needed for moderate pain. RN 5 stated Resident 41 also had a physician's order for oxycodone HCl 10 mg, give one tablet by mouth every four (4) hours as needed for severe pain (pain rated at seven [7] or higher out of 10, on a pain scale from zero [0] to 10, where 10 is the worst possible pain). Reviewed Resident 41's 6/2024 MAR with RN 5. RN 5 stated Resident 41 received oxycodone HCl 10 mg prn almost every day. When asked what nonpharmacological interventions were provided to Resident 41, RN 5 stated there was no documentation indicating the licensed nurses provided nonpharmacological interventions to Resident 41 prior to administering the prn opioid medication. RN 5 stated licensed nurses should be attempting nonpharmacological interventions prior to administering prn pain medication because it's possible that the resident may not need the medication. RN 5 stated the potential side effects the resident can experience from receiving too much opioid pain medication include an overdose or an increased risk of sedation. On 7/11/2024 at 10:12 a.m., during an interview, the DON stated it was important for nurses to attempt nonpharmacological interventions prior to administering prn opioid medications because it is possible the resident may not need the medication. The DON stated that opioid medications increased the risk for constipation, sedation, and falls. 2.c. A review of Resident 278's Admission Record indicated the facility admitted the resident on 7/3/2024 with diagnoses including cerebral infarction (a condition that occurs when blood flow to the brain is disrupted, causing an area of brain tissue to die). On 7/10/2024 at 8:32 a.m., during a concurrent interview and record review, reviewed Resident 278's physician's order with RN 5. RN 5 stated Resident 278 had a physician's order for Norco (a type of opioid medication used to treat pain) 5-325 mg, give one tablet every six (6) hours as needed for moderate to severe pain. Reviewed Resident 278's 7/2024 MAR with RN 5. RN 5 stated Resident 278 received Norco 5-325 mg on: - 7/7/2024 at 12:30 a.m. - 7/8/2024 at 3:13 a.m. and 6:45 p.m. - 7/9/2024 at 3:04 a.m. and 3:48 p.m. When asked what nonpharmacological interventions were provided to Resident 278, RN 5 stated there was no documentation indicating the licensed nurses provided nonpharmacological interventions to Resident 278 prior to administering the prn opioid medication. RN 5 stated licensed nurses should be attempting nonpharmacological interventions prior to administering prn pain medication because it's possible that the resident may not need the medication. RN 5 stated the potential side effects the resident can experience from receiving too much opioid pain medication include an overdose or an increased risk of sedation. On 7/11/2024 at 10:12 a.m., during an interview, the DON stated it was important for nurses to attempt nonpharmacological interventions prior to administering prn opioid medications because it is possible the resident may not need the medication. The DON stated that opioid medications increased