Other·November 18, 2021

F684 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. § 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. 6) Medications shall be administered as soon as possible, but no more than two hours after doses are prepared and shall be administered by the same person who prepares the doses for administration. Doses shall be administered within one hour of the prescribed time unless otherwise indicated by the prescriber. (8) Drugs may be administered in the absence of a specific duration of therapy on a licensed prescriber's new drug order if the facility applies its stop-order policy for such drugs. The prescriber shall be contacted prior to discontinuing therapy as established by stop-order policy. (c) The time and dose of the drug or treatment administered to the patient shall be recorded in the patient's individual medication record by the person who administers the drug or treatment. Recording shall include the date, the time and the dosage of the medication or type of the treatment. Initials may be used, provided that the signature of the person administering the medication or treatment is also recorded on the medication or treatment record. § 72311 - Nursing Service – General Nursing service shall include, but not be limited to, the following: Planning of patient care, which shall include at least the following: Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. An unusual occurrence, as provided in §72541, involving a patient. (E) Any untoward response or reaction by a patient to a medication or treatment. (G) The facility's inability to obtain or administer, on a prompt and timely basis, drugs, equipment, supplies or services as prescribed under conditions which present a risk to the health, safety or security of the patient. The Department received a complaint on 8/18/21regarding infection control and quality of care. On 8/31/21, an unannounced investigation was conducted at the facility. The facility failed to: a. Ensure timely ordering of Percocet (medication used to treat severe pain) for Resident 1. Resident 1 had chronic pain but did not receive her pain medication for three days. b. Ensure Resident 3 who was complaining of leg pain, was referred to the orthopedic doctor as ordered by the physician. c. Ensure Resident 2 who had a vaginal itching was assessed timely and provided prompt care. As a result, Residents 1, 2, 3 to suffered unnecessary pain, discomfort, and stress. a. A review of Resident 1's " Pain Management Review dated 1/20/21, indicated Resident 1 was prescribed Morphine Sulfate (a narcotic classified as a controlled substance, used to treatment severe pain) and Percocet (a combination of 2 medications, which is Oxycodone and acetaminophen, to relieve moderate to severe pain), 10 milligrams ([mg] unit of measurement) of Oxycodone and 325mg of acetaminophen. The record also indicated; Resident 1 had pain for the past five days. A review of Resident 1's, "Pain Management Review" record dated 8/4/21, indicated Resident 1 was prescribed routine Morphine Sulfate and oxycodone as needed "with complaints of pain (has chronic pain syndrome, watches the clock for her pain medications)." The pain management review record also indicated; Resident 1 had current pain. According to this record, Resident 1 also had pain within the past five days. The pain management record indicated the resident's pain was worse in the late evenings and affected Resident 1's concentration, emotions. The report indicated feeling anxious made the resident's pain worse. A review of the Resident 1 's Admission Records indicated the resident was admitted to the facility on 1/20/20, with diagnoses including, chronic pain syndrome (occurs when pain remains long after an illness or injury has healed; opioid (a strong pain medicine that causes addiction) dependence, and fusion of spine lumbar region (a surgical procedure to correct problems with the small bones in the spine). A review of Resident 1's History and Physical (H/P) record dated 2/22/2020, indicated the resident had the capacity to understand and make decisions. A review of Resident 1's Minimal Data Set ([MDS] a standardized assessment and care screening tool) dated 7/23/21, indicated the resident was able to understand and be understood. The MDS indicated Resident 1 required extensive one person assistance with bed mobility, transfer, dressing, toilet, and personal hygiene. A review of Resident 1's care plan for "Alteration in Musculoskeletal status" revised on 8/4/21 indicated, the resident's goal was to remain free from complications. The care plan interventions included to give analgesics (pain medicine) as ordered by the physician and to plan activities during optimal times when pain and stiffness was less. A review of Resident 1's care plan for "Opioid for Chronic Pain Syndrome" revised on 8/4/21, indicated the goal for Resident 1 was to remain free from pain or at a level of discomfort acceptable to the resident. The care plan intervention included to administer opioid as prescribed to reduce acute /chronic pain conditions. A review of Resident 1's "Restorative Nursing Assistant" (RNA) record dated 8/2021 indicated, Resident 1 refused RNA activities on 8/11/21 and 8/12/21 due to pain. A review of Resident 1's" Physician's Order Summary Report" dated 8/31/21, indicated the resident's diagnoses included spondylosis (a painful, age-related condition of the spine resulting in degeneration of the discs, and bones of the spine), lumbar (lower part of back) region, spinal stenosis (narrowing of the spaces within the spine, which can put pressure on the nerves that travel through the spine), and cervical (neck) region". The physician's orders also indicated, "Morphine Sulfate ER (extended release) Tablet, 12 Hour Abuse-Deterrent 60mg," 1 tablet by mouth every 12 hours for pain management, Percocet Tablet 10-325 mg 1 tablet by mouth every 4 hours as needed for moderate-severe pain and, Tylenol 325 mg, 2 tablets by mouth every 4 hours as needed for temperatures above 101. A review of Resident 1's "Medication Administration Record " (MAR) dated August 1-31, 2021, indicated Resident 1 received Morphine Sulfate ER every day at 0900 (9 a.m.) and 2100 (9 p.m.). A review of Resident 1's MAR dated August 1-31, 2021 indicated the resident received Percocet 10-325 mg as needed (PRN) every four hours. It also indicated with the exception of August 12-13, 2021. Resident received Percocet 10-325 mg from August 21 through 8/31/21, in which four (4) to six (6) doses were documented as administered, with the exception of 8/11/21, in which only two (2) doses were administered. The record also indicated on 8/12/21 and 8/13/21, Resident 1 did not receive any Percocet. According to the MAR, on 8/26/21 Resident 1 did not receive Percocet in the evening. The MAR also indicated on 8/27/21, Resident 1 only received one dose at 11:55 p.m. During a concurrent observation and interview on 8/31/21 at 12:41 p.m., Resident 1 stated she had chronic pain and did not receive her pain medication for two to three days. Resident 1 stated, when she asked the staff about her pain medication they would walk away. Resident 1 stated, around six different times the facility delayed ordering the Percocet and that "I had to suffer in pain for three to four days until the medication arrived." Resident 1 repeated that she needed her pain medication to treat her chronic pain, and that she felt stressed when the nurses would tell her she only had eight pills left and she worried, she would be in pain again without the medication. Resident 1 stated, the days she did not receive her pain medication she was in pain and did not want to do anything. Resident 1 cried as she stated, "I am so glad you are here!” A review of Resident 1's updated Percocet card and narcotic count sheet indicated the label was generated at the facility's dispensing pharmacy on 8/27/21. A review of the narcotic count sheet titled "Controlled Drug Record" indicated, an inventory of 60 tablets on 8/27/21 to 38 tablets on 9/1/21. The narcotic count sheet indicated a gap between 8/11/21 to 8/14/21, in which no doses were documented as administered on 8/12/21 and 8/13/21. During an interview on 9/1/21 at 1:22 p.m., Certified Nurse Assistant 4 (CNA) stated, "the resident often complained she was in pain on her legs and feet and requested her pain medication." CNA 4 stated, when the resident was in pain, she refused therapy. During an interview on 9/1/21 at 2:55 p.m., the Licensed Vocational Nurse 1 (LVN 1) stated Resident 1's Percocet was usually ordered when 7 or 10 tablets were remaining. LVN 1 stated physician's orders were faxed to the pharmacy. According to LVN 1, even if the order was entered in advance, the physician sometimes took long to sign off on narcotics and that delayed the pharmacy from dispensing the medication. During an interview on 9/1/21 at 3:25 p.m., with the Director of Nursing (DON) regarding the process of reordering controlled medications, she stated, "I always tell the nurses not to wait because the pharmacy is not going to dispense if the narcotics were not signed by the physician." The DON stated as soon as an order for narcotics was received, the licensed staff faxed it to the doctor's office for a signature. Regarding the delay in reordering Percocet and the three days it took to receive Resident 1's Percocet, the DON stated, "If the narcotic is not signed, the pharmacy will not deliver. Don't wait, because the patients use a lot of narcotics." According to the DON, it was hard getting signatures for narcotics and nurses had to communicate with the doctor to sign narcotic orders for fast delivery. During an interview on 9/2/21 at 2:58 p.m., the pharmacy manager, (Pharm 1) stated the Percocet order was faxed to the pharmacy on 8/24/21 and the physician signed the form on 8/27/21. Pharm 1 also stated "Sometimes it's hard to reach the physician." According to Pharm 1, "pharmacy staff e-mailed and faxed Resident 1's physician. The facility needs at least two (2) days for authorization. I don't know where the physician was, I can get someone to find out." During an interview on 9/1/21, at 4:07 p.m., Resident 1 stated her pain was worse each on 8/12-13/21 when she did not receive pain medication. The resident also stated when in pain, she would not have any appetite, would have a headache, nausea, unable to sleep or participate in her therapy. According to Resident 1 "it was too painful." During a concurrent interview and record review on 9/2/21, at 11:45 a.m., the DON stated Resident 1 received Percocet for the diagnosis of chronic pain syndrome. The DON stated Resident 1 would have increased pain. During a concurrent interview and record review on 9/2/21 at 12:44 p.m., Restorative Nurse Assistant 1 (RNA) stated Resident 1 refused RNA services on 8/12/21 due to pain. The RNA 1 stated he did not document the reason why Resident 1 refused RNA services. During an interview on 9/13/21 at 4:06 p.m., LVN 1 stated Resident 1 received Percocet, every four hours, as needed, for generalized pain. LVN 1 stated, Resident 1 had pain even after taking the pain medication. LVN 1 also stated, Resident 1 had a phone alarm that would go off every four hours as a reminder for pain management. According to LVN 1, Resident 1 knew when she was out of the Percocet and had agreed not to ask for the Percocet when the facility was running low on Percocet supply. LVN 1 stated, Resident 1 did not say her pain was "ok" without the Percocet medication and that she kept on asking the staff to follow up on the medication. During an interview on 9/13/21 at 5:11 p.m., LVN 2 stated Resident 1 suffered from pain daily and non-pharmacological interventions did not work for the resident's pain. LVN 2 stated, Resident 1 needed her pain medications all the time for generalized body pain. LVN 2 stated, the resident refused therapy each time she was in pain, and Resident 1 suffered from pain and anxiety when she didn't take Percocet. According to LVN 2, without Percocet the resident's pain may increase. A review of the facility's policy titled "Pain Management/ Assessment" revised on 5/2019 indicated the facility assisted each resident with pain to maintain or achieve the highest practicable level of well-being and functioning by screening to determine if the resident had been or experienced pain, comprehensively assessed the pain, identified circumstances when pain could be anticipated, developed and implemented a plan to manage the pain and or try to prevent the pain consistent with the resident's goals. The policy indicated pain findings, responses, and interventions were documented in the nursing notes. A review of the facility's undated "Licensed Vocational Nursing" job description indicated the LVN would report any complaints and grievances made by the resident regarding their medical care to the Director of Nursing and keep a written record of the resident's complaint with a notation of actions taken. B. A review of Resident 3's Admission Record indicated, the resident was originally admitted to the facility on 3/5/2018 and was readmitted on 11/6/2020. The resident's diagnoses included, Major Depressive Disorder ([MDD] a common but serious mood disorder that affects how you feel, think, and handle daily activities, such as sleeping, eating, or working), unspecified osteoarthritis (the wearing down of the protective tissue at the ends of bones) and polyneuropathy (nerve damage) A review of Resident 3's H/P record dated 11/8/20, indicated Resident 3 had the capacity to understand and make decisions. A review of Resident 1's physician's order dated 4/5/21, indicated orthopedic referral for severe osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down) of knee for possible intra-articular (a type of shot that is placed directly into a joint to relieve pain) injection (to reduce pain). A review of Resident 3's MDS a standardized assessment and care screening tool) dated 8/12/2021 indicated, Resident 3 was able to understand and be understood. The MDS indicated Resident 3 required extensive one person assistance with bed mobility, dressing, toileting, and personal hygiene. A review of Resident 3's Physician Progress Note dated 5/3/21 indicated, Resident 3 complained of leg pain. A review of another note dated 6/7/21, indicated Resident 3 continued to have the same pain complaints. A review of Resident 3's Pain Management Review record dated 5/6/2021 and timed at 1:52 p.m. indicated, Resident 3 was taking hydrocodone 5mg/acetaminophen (medication to relieve mild to chronic pain and fever), 325 mg ([Norco 5-325 mg] pain medication) and 50mg tramadol (medication to treat moderate to severe pain). The assessment record also indicated Resident 3 was not experiencing any pain. A review of Resident 3's physician's orders dated 8/31/, 21 indicated the resident was to be monitored for pain before, during and after treatment every shift, orthopedic (a branch of medicine concerned with the correction or pre