Other·May 9, 2024

42 CFR §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. 42 CFR §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident. 22 CCR §72311(a)(2) - Nursing Service - General (a)Nursing service shall include, but not be limited to, the following. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 22 CCR §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. (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the patient care policy committee. On 3/19/2023, during a standard annual recertification survey the California Department of Public Health (CDPH) determined the facility failed to ensure that on 3/20/2024, Resident 153, who sustained a fall with a right hip fracture, was medicated for excruciating pain in the right hip. Based upon observation, interview, and record review, the facility failed to: 1. Ensure the licensed nurses accurately assessed and documented Resident 153’s pain level and re-assessed the resident's pain level after administration of pain medication to evaluate medication effectiveness in relieving pain. 2. Notify Resident 153’s physician that the resident’s pain was not relieved with Tylenol (medication for mild pain relief) 325 milligrams ([mg] a unit of measurement of weight) two tablets every four hours, as needed. 3. Ensure the licensed nurses notified Resident 153's physician the resident was experiencing unmanageable and intolerable pain as care planned. 4. Ensure the licensed nurses assessed Resident 153's pain level every 30 to 60 minutes after the onset and reassessing as indicated for acute pain until the resident's pain was relieved in accordance with the facility's policy and procedure (P&P) titled, "Pain Assessment and Management." These deficient practices resulted in Resident 153 experiencing excruciating unrelieved pain due to a fall with the right hip fracture rated 10/10 on a pain rating scale (an assessment tool that measures pain levels, 0-no pain, 1-3 mild pain, 4-6 moderate pain, 7-10 severe pain) for almost 24 hours, from the first time the resident complained of pain on 3/8/2024 at 11:37 p.m., until she was transferred to a general acute care hospital (GACH) on 3/9/2024 at 10:24 p.m. At the GACH, the resident undergone right hip arthroplasty (removal of a broken bone and/or cartilage and replaced with prosthetic [manufactured replacement for a body part] components). Resident 153 also experienced severe unrelieved pain during her recovery from right hip arthroplasty from 3/14/2024 to 3/19/2024. Resident 153’s uncontrolled pain placed the resident at risk for a delay in physical therapy (a type of therapy that can help improve ability to stand and walk), improvement in ambulation, recovery from right hip surgery and development of depression. Findings: During a concurrent observation and interview on 3/19/2024 at 11:32 a.m., Resident 153 was observed in bed lying on a left side and yelling for help. Resident 153 stated she was in pain rated at 7/10. Resident 153 was observed with an uncovered right hip surgical incision with 23 staples without a dressing over the incision. Resident 153 stated she had fallen and broken her hip. Resident 153 stated she had received Tylenol 325 mg two tablets for pain that morning, but it was not relieving her pain. During a concurrent observation and interview with Resident 153 on 3/20/2024 at 10:15 a.m., Resident 153 was observed lying in bed on her left side. Resident 153 stated she was in the worst pain of her life. Resident 153 stated, the nurse gave her Tylenol 325 mg two tablets for pain that morning, but it was not working. During a concurrent observation and interview with Resident 153 on 3/21/2024 at 8:51 a.m., Resident 153 stated, she has been in pain since she fell on 3/8/2024, and the pain medication she was getting was not helping her pain. A review of Resident 153's Admission Record dated 1/22/2024, indicated Resident 153, an 81-year-old female, was admitted to the facility with diagnoses including major depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily activities), muscle weakness and hypertension (high blood pressure). A review of Resident 153's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 1/29/2024, indicated Resident 153 had severe impairment in cognitive (problems remembering things, solving problems, or making decisions) skills for daily decision making. The MDS indicated Resident 153 had no impairment (ability to perform an activity without restriction) in the upper or lower extremities (arms and legs). A review of Resident 153's Change of Condition (COC) form dated 3/8/2024 at 11:37 p.m., indicated Resident 153 complained of right hip pain, without bruising and swelling, skin intact upon assessment. The COC indicated Resident 153 needed assistance with positioning in bed due to pain, and an x-ray (imaging of internal organs and bones) of the right hip was ordered. A review of Resident 153's Physician's Order dated 3/8/2024 and timed at 12:45 a.m., indicated an order for an X-ray due to the resident's right hip pain. A review of Resident 153's COC form dated 3/8/2024 at 11:37 p.m., indicated Resident 153 had a decline in ambulation (ability to walk) and mobility (movement from place to place) and required a pain assessment due to the reported COC and occasional moaning and groaning. The COC form indicated Resident 153's body language was tense, distressed and fidgeting (physical reaction to relieve pain). A review of Resident 153's Medication Administration Record (MAR) dated 3/8/2024 (the date Resident 153 fractured her hip), did not indicate Resident 153 was assessed and medicated for pain. A review of Resident 153's X-ray report of the right hip dated 3/9/2024 and timed at 12:59 p.m., indicated Resident 153 had a right sub-capital (neck of the thighbone) fracture with moderate displacement (when ball of the hip joint is pushed out of the socket) of the right hip. A review of Resident 153's physician's orders (PO) dated 3/9/2024, indicated an order for Tylenol 325 mg two tablets every four hours as needed (prn) for mild pain level of 1/10 to 3/10 (reference range 1-3 mild pain, 4-7 moderate pain, 8-10 severe pain) A review of Resident 153's Progress Notes dated 3/9/2024 at 10:24 p.m., indicated Resident 153 was picked up by transportation and taken to the GACH, over 10 hours after the X-ray report indicated the resident had a right hip fracture. The X-ray report result was sent to the facility on 3/9/2024 at 12:59 p.m. in the afternoon. A review of Resident 153's GACH's record dated 3/12/2024, indicated Resident 153 had a right hip arthroplasty. A review of Resident 153' s Progress Notes dated 3/12/2024 at 2:56 p.m., indicated Resident 153 was transferred back to the facility from GACH. The Progress Notes indicated Resident 153 was unable to walk due to her right hip fracture. A review of Resident 153's PO dated from 3/14/2024 to 3/19/2024, indicated Resident 153 only had Tylenol 325 mg two tablets every four hours prn ordered after arthroplasty surgery for a broken right hip on 3/12/2024. A review of Resident 153's care plan revised on 3/15/2024, indicated Resident 153 was at Risk for Pain or Discomfort due to status post (after) right hip arthroplasty. The care plan goals for Resident 153 were to have pain relieved to a tolerable level as indicated by the resident, using verbal or non-verbal communication and to express pain relief after administration of medication. The care plan interventions were to administer medication as ordered, assess pain every shift and as indicated, and notify physician if resident experiences unmanageable or intolerable pain. A review of Resident 153's Physical Therapy (PT) evaluation dated 3/15/2024, indicated Resident 153 had a pain level rated 7 out of 10 upon movement of the right hip, aching (pain that occurs continuously in a localized area) in intensity and intermittent (pain that comes and goes) in frequency. The PT evaluation indicated the pain limited Resident 153's right leg movement, bed mobility, and transfers out of bed. A review of Resident 153's PT progress note dated 3/18/2024, indicated during attempted physical therapy Resident 153 was screaming out and physically combative, hitting the therapist due to pain. The PT progress note indicated the charge nurse (unspecified) came into the room and stated Resident 153 was already given Tylenol 325 mg two tablets for pain. A review of Resident 153's MAR dated 3/18/2024, Resident 153's pain levels were documented as 0/10 for the day, evening, and night shifts. A review of Resident 153's PT progress note dated 3/19/2024, indicated Resident 153's pain level with movement was 7/10. The PT progress note indicated when Resident 153 was repositioned, she started screaming out because of pain despite Resident 153 being medicated with Tylenol 325 mg two tablets prior to treatment. A review of Resident 153's PO dated from 3/14/2024 to 3/28/2024, indicated Resident 153 had an order for Tylenol 325 mg two tablets every four hours prn for mild pain level of 1-3. A review of Resident 153's MAR dated 3/19/2024 at 11:32 a.m., indicated Resident 153 had a pain level of 4/10 and was given Tylenol 325 mg two tablets (ordered for mild pain levels of 1-3). A review of Resident 153's PO dated from 3/19/2024 to 3/20/2024, indicated Resident 153 had an order for Tramadol (medication used to help relieve moderate to moderately severe pain. Tramadol belongs to a class of drugs known as opioid [narcotic] analgesics [medication that relieve pain]) 50 mg every eight hours as needed for pain. The PO did not indicate a criteria for pain level to administer the Tramadol. Tramadol was ordered 5 days after Resident's 153 had been in unrelieved pain from the two tablets of Tylenol 325 mg that were administered prn every four hours as ordered. A review of Resident 153's MAR dated 3/19/2024 at 2:42 p.m., indicated Resident 153 had a pain level of 10/10, and was given Tramadol 50 mg. A review of Resident 153's PT Progress Notes dated 3/20/2024, indicated Resident 153's pain level with movement was 7/10. The PT Progress Notes indicated Resident 153 was very guarded (protective from movement that causes pain) with gentle passive range of motion ([PROM] someone physically moves or stretches a part of your body) and started screaming out in pain despite being medicated with Tylenol 325 mg two tablets prior to PT therapy. During an interview on 3/21/2024 at 8:48 a.m., Resident 153 stated after she fell on 3/4/2024 she told a staff member but does not remember who, that she was in excruciating pain rated 10/10. Resident 153 stated she was given pain medication that morning, but it did not relieve her pain. During an interview on 3/21/2024 at 10:37 a.m., the Physical Therapist (PT 1) stated he saw Resident 153 for Range of Motion (ROM) therapy on 3/9/2024 and she was in pain. PT 1 stated Resident 153 was not able to walk, and he did not ask the resident what happened to her. PT 1 stated he reported Resident 153 was having pain to Licensed Vocational Nurse (LVN 2), but she (LVN 2) stated she was already aware. PT 1 stated Resident 153 was moaning in pain, so he stopped the treatment. During an interview on 3/22/2024 at 3:35 p.m., LVN 7 stated Resident 153 had a fall on 3/8/2024 after 3 p.m. LVN 7 stated Resident 153 was in too much pain the morning of 3/9/2024 and could not work with PT. During an interview on 3/26/2024 at 2:45 p.m., Certified Nurse Assistant (CNA 6) stated her coworkers (unable to identify coworker) reported to her that Resident 153 had a fall on 3/8/2024 and broke her hip. CNA 7 stated Resident 153 was ambulatory (able and strong enough to walk; not confined to a bed) before the fall and able to take care of herself. CNA 7 stated Resident 153 was very depressed after the fall. CNA 6 stated it was hard to move Resident 153 during daily care because she was in a lot of pain. A review of the facility’s P&P titled "Pain Assessment and Management" revised 10/2022, indicated the purposes of this procedure is to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. The P&P indicated the pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. The P&P indicated "Pain management" is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals. The P&P indicated cognitive, cultural, familial, or gender-specific influences on the residents' ability or willingness to verbalize pain are considered when assessing and treating pain. The P&P indicated comprehensive pain assessments are conducted upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. The P&P 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: 1. Ensure the licensed nurses accurately assessed and documented Resident 153’s pain level and re-assessed the resident's pain level after administration of pain medication to evaluate medication effectiveness in relieving pain. 2. Notify Resident 153’s physician the resident’s pain was not relieved with Tylenol (medication for mild pain relief) 325 milligrams ([mg] a unit of measurement of weight) two tablets for pain. 3. Ensure the licensed nurses notified Resident 153's physician the resident was experiencing unmanageable and intolerable pain as care planned. 4.Ensure the licensed nurses assessed Resident 153's pain level every 30 to 60 minutes after the onset and reassessing as indicated for acute pain until the resident's pain was relieved in accordance with the facility's P&P titled, "Pain Assessment and Management." These deficient practices resulted in Resident 153 experiencing excruciating unrelieved pain due to a fall with the right hip fracture rated 10/10 on a pain rating scale for almost 24 hours, from the first time the resident complained of pain on 3/8/2024 at 11:37 p.m., until she was transferred to a GACH on 3/9/2024 at 10:24 p.m. At the GACH the resident undergone right hip arthroplasty. Resident 153's uncontrolled pain placed the resident at risk for a delay in physical therapy improvement in ambulation, recovery from right hip surgery and development of depression. These violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 153.