Health inspection·November 8, 2024

§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. On 9/16/2024, the California Department of Public Health (CDPH) received a complaint alleging a resident (Resident 1), who requested pain medication at 11:40 p.m., did not receive pain medication until 1:45 a.m. because the nurse (Registered Nurse 1 [RN 1]) who was assigned to give her the pain medication was helping other residents, but later found out RN 1 left the facility for two hours On 9/25/2024, CDPH conducted an unannounced visit to the facility to investigate the complaint allegation. The CDPH determined Resident 1, who complained of a pain level of eight out of 10 on a pain rating scale where pain is rated from zero to 10; (0=no pain, 1-3=mild pain, 4-6=moderate pain, and 7-10=severe pain, and 10=worst imaginable pain), was not medicated to control her pain for two hours. The facility failed to: 1. Ensure Resident 1 received Oxycodone-Acetaminophen (a medication used to help relieve moderate to moderately severe pain) 5-325 milligrams ([mg] a metric unit of measurement, used for medication dosage and/or amount), when she complained of a pain level of eight out of 10 on a pain rating scale from zero to 10. 2. Ensure keys to the medication cart were endorsed to a licensed nurse during the 11 p.m., to 7 a.m., shift and not locked in a medication room where licensed nurses could not access them after Registered Nurse Supervisor (RNS 1) left the facility and took the keys to the medication room with him. 3. Contact Resident 1's physician and/or the facility's pharmacy to request access to the facility's Emergency Kit ([E-Kit] a kit containing a small supply of medication that can be dispensed when medication was not available) to obtain pain medication to administer to Resident 1. 4. Ensure licensed nurses contacted the Director of Nursing (DON), for instructions on how to access the medication cart keys, when Resident 1 complained of a pain level of eight out of 10 and they were unable to access Resident 1's prescribed pain medication in the facility's medication cart and/or the E-Kit after RNS 1 took the supervisor's keys with him when he left the facility. 5. Ensure Licensed Vocational Nurse 1 (LVN 1), when she was made aware of Resident 1's complaint of pain, assessed Resident 1's pain level and implemented interventions, such as talking to her in a soothing tone to deescalate her anxiety and reassure her, that her needs would be met, to minimize and/or relieve Resident 1's pain, according to Resident 1's care plan. 6. Follow the facility's policy and procedure (P/P) titled, "Pain Management," indicating the facility would help a resident attain or maintain his/her highest practicable level of physical, mental, and psychosocial well-being by preventing or managing the pain consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goal and preferences. These failures resulted in Resident 1 experiencing increased, unrelieved severe pain for approximately two hours. Resident 1 became angry, and her anxiety (feelings of fear, dread, and uneasiness that may occur as a reaction to stress) level went "through the roof" as she paced in the hallways of the facility due to unrelieved severe pain. A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1, a 58 year old female, was admitted to the facility on 11/30/2023 with the diagnosis including right knee osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), a right artificial knee joint (a man-made joint that replaces a damaged knee joint), major depressive disorder ([MDD] a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). A review of Resident 1's Minimum Data Set ([MDS] a federally mandated resident assessment tool) dated 9/7/2024 indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact and Resident 1 required supervision or touch assistance (the helper provides verbal cues and/or touching/steadying as the resident completes activity) to complete activities of daily living ([ADLs] routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). A review of Resident 1's Physician's Orders dated 11/30/2023 indicated Resident 1 was to receive Oxycodone-Acetaminophen 5-325 mg, two tablets, every four hours as needed for severe pain (8-10). A review of Resident 1's Care Plan dated 9/5/2024 indicated Resident 1 had panic attacks due to overwhelming stressors related to the fear of not getting her controlled, as needed, every four hours pain medication, as evidenced by claimed hyperventilation (rapid or deep breathing, usually caused by anxiety or panic), palpitations (abnormally rapid or irregular beating of the heart usually caused by panic, agitation, or exercise), and dizziness. Under this care plan, goals were set for Resident 1 to demonstrate reduced anxiety levels, as evidenced by controlled breathing, reduced heart rate, and verbalization of feelings. The care plan's interventions included ensuring as needed pain medications were available when needed to manage Resident 1's pain and to provide reassurance to deescalate the situation, speak in a calm and soothing tone, and reassure Resident 1 that her needs would be met. A review of Resident 1's Medication Administration Record [(MAR] a record used to document medications taken by each individual) dated 9/2024 indicated on 9/15/2024 at 1:30 a.m. Resident 1 complained of a pain level of eight out of 10 and was administered two tablets of Oxycodone-Acetaminophen 5-325 mg. During an interview on 9/24/2024 at 10:17 a.m., Resident 1 stated on 9/14/2024, she pressed her call light around 11:40 p.m., because her pain was between 8-9 out of 10. Resident 1 stated she saw Certified Nursing Assistant (CNA 1) in the hallway and told CNA 1 that she was in pain and wanted her pain medication. Resident 1 stated CNA 1 told her, she (CNA 1) would inform one of the licensed nurses that she (Resident 1) was in pain. Resident 1 stated no nurse came to her room and she became impatient, so she walked to the Nursing Station II, to request pain medication and was told by LVN 2 and RNS 2 that her assigned nurse (LVN 1) was busy with another resident. Resident 1 stated RNS 2 told her that she (RNS 2) could administer the pain medication to her (Resident 1). Resident 1 stated by 12 a.m., RNS 2 had not come back to her room with her pain medication, so around 12:30-12:35 a.m., she (Resident 1) decided to sit at the Nursing Station II and wait. Resident 1 stated approximately 18 minutes later RNS 1 entered the facility, and she (Resident 1) observed RNS 1 give the keys to the medication cart to LVN 1. Resident 1 stated she received her pain medication at 1:45 a.m., (over two hours after she requested it on 9/14/2024 at 11:40 p.m.). Resident 1 stated by the time she finally receive her medication her pain had increased to 10 out of 10 and her anxiety was "through the roof" because of her pain, waiting for someone to give her pain medication and wondering when she would receive the pain medication. During a phone interview on 9/25/2024 at 4:06 p.m., CNA 1 stated on 9/14/2024 (she could not remember the time), Resident 1 kept complaining that she was in pain and how it was taking the licensed nurses a long time to respond. CNA 1 stated she reported to the licensed staff a couple of times that Resident 1 was upset because she was in pain and wanted pain medication. CNA 1 stated there were no licensed nurses available to give Resident 1 pain medication and RNS 1, who had the key to the medication cart, was not at the facility. CNA 1 stated she saw Resident 1 in the hallway, upset, because she (Resident 1) was told LVN 1 was the only one who could give her (Resident 1) medication, because she (LVN 1) had the keys to the medication cart, but LVN 1 was not available. During a telephone interview on 9/25/2024 at 4:16 p.m., RNS 1 stated on 9/14/2024, during the 3 p.m., to 11 p.m., to the 11 p.m., to 7 a.m., change of shift, he was given keys by RNS 2, but stated he did not check to see what the keys were for, and he left them locked in the medication room when he left the facility to get supplies from another facility. RNS 1 stated LVN 1 called him on his cell phone looking for the keys to the medication cart, and that was when he realized the supervisor's key, that opened the medication room, the Director of Nursing's (DON) office, and the supply room, were in his pocket. RNS 1 stated when he returned to the facility, Resident 1 was sitting at the nurses' station, she was upset and waiting for her pain medication. RNS 1 stated Resident 1 should not have had to wait for pain medication for over two hours. During an interview on 9/26/2024 at 5:59 a.m., LVN 1 stated on 9/14/2024, she came to work late, and started her shift at 12:54 a.m., (9/15/202), she was told that RNS 1 had the keys to the medication cart, but RNS 1 was not at the facility. LVN 1 stated she called RNS 1 around 1:13 a.m., and again at 1:14 a.m., to ask him about the keys to the medication room and the medication cart because Resident 1 was in pain and was asking for pain medication. LVN 1 stated she could have given Resident 1 pain medication from the facility's E-Kit, but she did not have access to the E-Kit because it was located in the medication room, which was locked and RNS 1 had the keys to the medication room. LVN 1 stated when Resident 1 came to Nursing Station II, she was upset and stated she had been in excruciating pain (pain that is extremely painful, causing intense suffering, or unbearably distressing) since 11 p.m., (9/14/2024). During a telephone interview on 9/26/2024 at 8:26 a.m., LVN 2 stated on 9/14/2024 after 11 p.m., she overheard Resident 1 asking for pain medication and observed Resident 1 at Nursing Station II (time is unknown), yelling at RNS 1, when RNS 1 returned to the facility, about the medication cart key and her pain medication. LVN 2 stated Resident 1 was "ballistic" (extremely and usually suddenly excited, upset, or angry) and very unhappy with RNS 1. LVN 2 stated Resident 1 not receiving her pain medication when she (Resident 1) complained of pain could have been avoided if RNS 1 had not taken the keys to the medication room with him when he left the facility. During an interview on 9/26/2024 at 9 a.m., the DON stated during change of shift, the licensed nurses count the narcotics in the medication cart and the keys to the medication cart are given to the oncoming licensed nurse. The DON stated on 9/14/2024, LVN 1 began her shift late (9/15/2024 at 12:54 a.m.) and RNS 1 had the supervisor's keys with him when he left the facility. The DON stated the facility staff should have notified her if they had a problem opening the medication room, because the other LVN, who was at the facility, had the keys that could have opened the medication room, and if they did not know that she could have told them, or the facility staff could have called the physician and pharmacy to open the E-kit. The DON stated Resident 1 should not have had to wait over two hours for pain medication, and this caused Resident 1's pain and increased anxiety when the resident could not get her medication. A review of the facility's P/P titled "Pain Management" dated 12/19/2022 indicated the facility will help a resident attain or maintain his/her highest practicable level of physical, mental, and psychosocial well-being by preventing or managing the pain consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goal and preferences. The facility failed to: 1. Ensure Resident 1 received Oxycodone-Acetaminophen mg, when she complained of a pain level of eight out of 10 on a pain rating scale from zero to 10. 2. Ensure keys to the medication cart were endorsed to a licensed nurse during the 11 p.m., to 7 a.m., shift and not locked in a medication room where licensed nurses could not access them after RNS 1 left the facility and took the keys to the medication room with him. 3. Contact Resident 1's physician and/or the facility's pharmacy to request access to the facility's E-Kit to obtain pain medication to administer to Resident 1. 4. Ensure licensed nurses contacted the DON, for instructions on how to access the medication cart keys, when Resident 1 complained of a pain level of eight out of 10 and they were unable to access Resident 1's prescribed pain medication in the facility's medication cart and/or the E-Kit after RNS 1 took the supervisor's keys with him when he left the facility. 5. Ensure LVN 1, when she was made aware of Resident 1's complaint of pain, assessed Resident 1's pain level and implemented interventions, such as talking to her in a soothing tone to deescalate her anxiety and reassure her, that her needs would be met, to minimize and/or relieve Resident 1's pain, according to Resident 1's care plan. 6. Follow the facility's P/P titled, "Pain Management," indicating the facility would help a resident attain or maintain his/her highest practicable level of physical, mental, and psychosocial well-being by preventing or managing the pain consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goal and preferences. These failures resulted in Resident 1 experiencing increased, unrelieved severe pain for approximately two hours. Resident 1 became angry, and her anxiety level went "through the roof" as she paced in the hallways of the facility due to unrelieved severe pain. These violations had a direct relationship to the health, safety, or security of residents.