Health inspection·April 5, 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. §483.35 Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e). §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents or obtain them under an agreement described in §483.70(g). §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. § 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. § 72355 - Pharmaceutical Service - Requirements (a) Pharmaceutical service shall include, but is not limited to, the following:(1) Obtaining necessary drugs including the availability of 24-hour prescription service on a prompt and timely basis as follows: (3) Monitoring the drug distribution system which includes ordering, dispensing and administering of medication. 22 CCR § 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 . On 2/12/2024, the California Department of Public Health (CDPH) received a complaint alleging the facility admitted a resident (Resident 1), who was taking pain medication every three hours for severe pain following two surgeries prior to admittance to the facility. The facility's staff did not have and was not able to obtain Residents 1's pain medication until the next day. On 2/13/2024, CDPH conducted an unannounced visit to the facility to investigate the allegation. The CDPH determined Resident 1 was admitted to the facility for pain management from a General Acute Care Hospital (GACH) following two spinal fusion (a surgical procedure to connect two or more bones in the lower part of the spine) surgeries and was not medicated to control her pain. As a result of the investigation, CDPH determined the facility failed to: 1. Provide Dilaudid (a narcotic medication used to treat moderate to severe pain) for approximately six hours to Resident 1, who complained of a pain level of 10 out 10 on a 0 to 10 pain rating scale (where 0 is equal to no pain and 10 is equal to the worst pain possible). 2. Follow up with the facility's pharmacy to confirm the pharmacy received the faxed order for Dilaudid. 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 the medication is not available from the pharmacy) in order to obtain Dilaudid to administer to Resident 1 for a pain level rated 10 out of 10. In accordance with the facility's policy and procedure (P/P), "Emergency Pharmacy Service and Emergency Kits." 4. Ensure Resident 1 administered pain medication that was appropriate for pain rated at a 10 out of 10 and not administered Tylenol which was prescribed for mild pain rated 1-3 5. Ensure Licensed Nurses followed Resident 1's Care Plan that indicated to evaluate Resident 1's pain, to medicate Resident 1 with pain medication as need and to evaluate the effectiveness of Resident 1's pain medication. 6. Ensure Licensed Vocational Nurse 1 (LVN 1) was knowledgeable regarding the purpose of the E-Kit and was trained including instructed when the E-Kit should be used, on the protocol, and procedure necessary to access the medications that were in the E-Kit. 7. Ensure LVN 1, when she was made aware of Resident 1's pain level rated 10 out of 10, continued to assess and monitor Resident 1's status and document the care provided to Resident 1 to relieve the resident's pain in accordance with the facility's P/P, titled "Pain Management." 8. Follow the facility's policy and procedure (P/P), titled, "Pain Management," indicating the facility must ensure 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. These deficient practices resulted in Resident 1 experiencing increased, unrelieved severe and intense pain for approximately six hours. The lack of pain management placed Resident 1 at risk for alteration in sleep, appetite, mental health, and delay in recovery. A review of Resident 1's GACH's Admission Record, indicated Resident 1, a 66 year-old-female, was admitted to the GACH on 2/2/2024. A review of Resident 1's Neurosurgery (a branch of medicine that is concerned with the diagnosis and treatment of nervous system disorders) Operative report, from the GACH, dated 2/2/2024, indicated Resident 1 had a lumbar (lower part of the back) two to lumbar three lateral retroperitoneal approach (surgery performed through an incision over the patient's side) surgery with discectomy (surgical removal of the damaged portion of the disk in the spine) and insertion of a biomechanical device (spine surgery to connect two or more bones with screws in the lower part of the spine). A review of Resident 1's Neurosurgery Operative report dated 2/6/2024, indicated Resident 1 had a lumbar one to lumbar three intertransverse (between the bones of the spine) and posterolateral (on the side and toward the back of the body) lumbar fusion (back surgery where the spine is fused together to treat pain) surgery. A review of Resident 1's GACH Medication Administration Record (MAR) dated 2/10/2024, indicated Resident 1 received Dilaudid 1 milligram (mg) at 2:24 a.m., 5:38 a.m., 8:58 a.m., 12:26 p.m., 3:30 p.m., and 6:35 p.m. A review of Resident 1's GACH Discharge Summary Note dated 2/10/2024, indicated Resident 1's pain was managed well with a Fentanyl patch (narcotic medication used to treat moderate to severe pain in the form of a patch placed on a person's skin) and Dilaudid medication. A review of Resident 1's Admission Record (Face Sheet) from the facility, indicated Resident 1 was admitted on 2/10/2024 with the diagnosis of fusion of the lumbar region of the spine (a surgical procedure to permanently join two or more bones in the spine so there is no movement between them). A review of Resident 1's History and Physical (H&P) dated 2/12/2024, indicated Resident 1 had the mental capacity to make decisions. The H&P indicated the plan for Resident 1 was for pain management. A review of Resident 1's Physician's Orders dated 2/10/2024, indicated the following medications were prescribed to Resident 1 for pain: 1. Dilaudid 1 mg tablet every three hours as needed for moderate pain (4-6) and severe pain (7-10). 2. Tylenol (a medication used to treat minor aches, pains, and fever) 650 mg tablet every four hours as needed for mild pain (1-3). A review of Resident 1's Care Plan for Acute/Chronic Pain dated 2/10/2024, indicated Resident 1 had acute/chronic pain and the goal was for Resident 1 to report satisfactory pain control. The Care Plan's interventions included evaluating Resident 1's pain, medicating Resident 1 with pain medication as needed and evaluating the effectiveness of the pain medication. A review of Resident 1's MAR dated 2/11/2024, indicated Tylenol 650 mg was administered to Resident 1 on 2/11/2024 at 2:36 a.m., for a pain level rated 10 out of 10. A review of the facility's Narcotic Emergency Box (E-Kit) indicated the list of contents dated 12/31/2024 included four tablets of Dilaudid 2 mg per tablet and a 2 mg injectable vial of Dilaudid. During an interview on 2/13/2024 at 11:46 a.m., and a subsequent interview on 2/16/2024 at 10:35 a.m., Resident 1 stated she was given pain medication at the GACH at approximately 6:40 p.m., on 2/10/2024, before she was transferred to the facility and her pain was under control when she arrived at the facility. Resident 1 stated she began asking about the status of the Dilaudid delivery at approximately 11 p.m., on 2/10/2024 because she did not want to wait until the pain was unmanageable. Resident 1 stated she was given different reasons why the Dilaudid was not available. Resident 1 stated the next time she received Dilaudid at the facility was 8:30 a.m., on 2/11/2024 and by that time she was delirious with pain. Resident 1 stated her pain was an 18 out of 10 (indicating it was worse than a 10 on the pain scale). Resident 1 stated on 2/11/2024 at 2:30 a.m., she was in the bed hollering, screaming in pain and crying for someone to help her. Resident 1 stated she experienced a burning sensation which extended from her lower back to her upper thighs. Resident 1 stated the pain continued to get worse, she reported it to the staff, they offered her Tylenol, and she took the Tylenol knowing it would not help stop the pain. During a telephone interview on 2/13/2024 at 3:35 p.m., Resident 1's Family Member (FM) stated when she spoke to the facility's staff on 2/10/2024 she was told the facility did not have Resident 1's Dilaudid pain medication and she (FM) even offered to pick it up. Resident 1's FM stated she spoke to the morning charge nurse on 2/11/2024 and was told the Dilaudid was available in the facility's E-kit. Resident 1's FM stated it was so hard to hear her sister in tears because of the pain she (Resident 1) experienced throughout the night. During an interview on 2/14/2024 at 11:46 p.m., Registered Nurse Supervisor 1 (RNS 1) stated he admitted Resident 1 to the facility on 2/10/2024 at approximately 8 p.m., and he faxed Resident 1's medication orders to the pharmacy but the medications were not delivered before the end of his shift (3 p.m. to 11 p.m.). RNS 1 stated Resident 1's FM came to the facility on 2/11/2024 around 7 a.m., upset because Resident 1 had not received any pain medication throughout the night. RNS 1 stated he refaxed the medication orders to the pharmacy on 2/11/2024 and received authorization from the pharmacy to access the E-kit to obtain the Dilaudid. RNS 1 stated the purpose of the E kit was to have medication available if the pharmacy was not able to deliver it, if medications were missing, or if the resident was newly admitted and needed medication immediately. During an interview on 2/14/2024 at 12:18 p.m., the MDS Nurse (a nurse who collects and assesses information for the health and well-being of residents in a Medicare or Medicaid certified nursing facility) stated if medication was not delivered by the pharmacy, licensed nurses could contact the physician to obtain authorization to get medication from the E-Kit and administer it as onetime dose to a resident. The MDS Nurse stated Resident 1 received Tylenol 650 mg on 2/11/2024 at 2:36 a.m., for a pain level rated 10 out of 10, but the Tylenol was prescribed for a mild pain (1-3). The MDS Nurse stated there was no documentation to indicate if the Tylenol was effective in relieving Resident 1's pain. The MDS Nurse stated pain medication effectiveness should be reassessed 30 minutes to one hour after administration of pain medications. The MDS Nurse stated if the pain medication was not effective the resident's physician should be contacted for additional instructions or to authorize access to the E-Kit, if the resident's physician could not be reached, the medical director should be called. During an interview on 2/14/2024 at 1:13 p.m., and subsequent interviews on 2/16/2024 at 10:04 a.m., and at 4:01 p.m., LVN 1 stated Resident 1 was admitted to the facility on 2/10/2024 and her pain began that night between 11 p.m., and 12:30 a.m. LVN 1 stated Resident 1's FM called the facility around midnight asking what could be done for Resident 1 to relieve her pain. LVN 1 stated she explained to Resident 1's FM that Resident 1 would have to wait for the pain medication to be delivered. LVN 1 stated she did not contact Resident 1's physician or the pharmacy because the pain medication had already been ordered and she thought it would arrive during the first delivery (1 a.m. - 2 a.m.). LVN 1 stated she administered Tylenol 650 mg to Resident 1 because that, was the only pain medication available. LVN 1 stated Resident 1 agreed to take Tylenol even though she (Resident 1) knew it would not relieve her pain. LVN 1 stated she checked on Resident 1 after the Tylenol was given to her and Resident 1 was still in pain. LVN 1 stated she did not notify Resident 1's physician of Resident 1's unrelieved pain. LVN 1 stated she was expecting and hoping Resident 1's pain medication would be delivered from the pharmacy during her shift (11 p.m. to 7 a.m.) but it was not delivered. LVN 1 stated when RNS 1 arrived the next morning (2/11/2024), she and RNS 1 called the pharmacy to obtain authorization to access the E-Kit and administered Dilaudid 1 mg to Resident 1. LVN 1 stated she thought the E-Kit was for specific residents and not intended for Resident 1's use, she did not know how to access the medications in the E kit, and she did not understand the medications in the E-Kit were for any resident that needed them. LVN 1 stated she was not provided training on the E-Kit during her orientation. A review of the facility's Emergency Kit Pharmacy Log, the log indicated Resident 1 received a half tablet of a Dilaudid 2 mg tablet on 2/11/2024 at 7:45 a.m. During an interview on 2/15/2024 at 2:30 p.m., the Pharmacy Nurse Executive stated when the facility gets a new admission, the facility's licensed nurses should fax the medication order to the pharmacy and follow up with a phone call in 20 minutes to ensure the pharmacy received the fax. During an interview on 2/15/2024 at 3:11 p.m., the Director of Pharmacy Operations stated if a resident was experiencing pain and the resident's physician was unavailable, the pharmacist could assess the resident's profile to give a onetime authorization for the resident to receive pain medication. During an interview on 2/15/2024 at 3:45 p.m., and a subsequent interview on 2/16/2024 at 12:07 p.m., the RDCO (Regional Director of Clinical Operations) stated if medication had not arrived from the pharmacy, the licensed nurses should follow up with the pharmacy, the resident's physician and if the resident's physician was not available, the licensed nurses should call the medical director. The RDCO stated the purpose of the E-Kit was to provide medication to residents when medication was not available from the pharmacy or if there was an emergency situation. The RDCO stated if the resident does not receive pain medication, they could experience continued pain or an increased intensity in pain. A review of the facility's P/P, titled "Medication Administration," dated 10/2022, the P/P indicated medications s