Other·May 23, 2023

F 697 FCR §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. CCR§ 72311. Nursing Service - General. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) 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. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited. (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (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: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. CCR § 72315. Nursing Service - Patient Care. (a) Each patient shall be encouraged and/or assisted to achieve and maintain the highest level of self-care and independence. Every effort shall be made to keep patients active, and out of bed for reasonable periods of time, except when contraindicated by orders of a licensed health care practitioner acting within the scope of his or her professional licensure. On 3/16/2023 at 9:30 a.m., the California Department of Public Health (DPH) conducted an unannounced visit to the facility to investigate a multiple allegation complaint. As a result of the investigation, the California Department of Public Health (CDPH) determined that the facility failed to manage Patient 3’s pain by failing to: 1. Ensure Licensed Vocational Nurse 1 (LVN 1) assessed Patient 3's leg pain (pain on both legs) and re-evaluated the effectiveness of the Tylenol (pain relief medication) administration on 3/16/23, at 2 p.m. as indicated in Patient 3's care plan for pain. 2. Ensure LVN 1 implemented the facility's policy and procedure titled, "Nursing Administration," when LVN 1 did not notify Medical Doctor 1 (MD 1) regarding Patient 3's uncontrolled/unrelieved leg pain (unrated). As a result of this failure, on 3/16/23 and on 3/17/23, Patient 3 experienced physical and emotional distress due to unrelieved and uncontrolled pain on both legs. A review of Patient 3's Admission Record indicated Patient 3 was a 64-year old male and was admitted to the facility on 10/18/22 with diagnoses that included sepsis (a life-threatening complication of an infection) and contractures (shortening and hardening of muscles, tendons, or tissues leading to deformity and joint stiffness) on both knees. A review of Patient 3's Care Plan for Pain, initiated on 10/18/22, revised on 1/1/23, indicated Patient 3 was at risk for alteration in comfort related to pain manifested by complaints of pain, facial grimace (facial expression of disgust or pain), guarded movements (stiff or rigid movements). The goal was for Patient 3 not to have interruptions in normal activities due to pain. The nursing interventions included for nursing staff (in general) to anticipate the need for pain relief, respond immediately to any complaint of pain, and evaluate the effectiveness of pain interventions. A review of Patient 3's History and Physical (H&P), dated 10/28/22, indicated Patient 3 did not have the capacity to understand and make decisions. A review of Patient 3's Minimum Data Set (MDS, a comprehensive assessment and a care planning tool), dated 1/22/23, indicated Patient 3 had severe cognitive (processes of thinking and reasoning) impairment and had unclear speech. The MDS indicated Patient 3 required extensive assistance (patient involved in activities, staff provide weight bearing support) with bed mobility, dressing, and toilet use. The MDS indicated Patient 3 received a scheduled pain medication regimen. A review of Patient 3's Order Summary Report, active orders as of 3/1/23, indicated Patient 3 had the following physician orders: 1. Order dated 10/18/22, indicated pain assessment according to scale: 0 = no pain, 1 to 3 = mild pain, 4 to 6 = moderate pain, and 7 to 10 = severe pain. 2. Order dated 10/18/22, indicated Tylenol, tablet, 500 milligrams (mg, unit of measurement), one tablet given via feeding tube [a tube that is inserted through the nose, down the throat and esophagus (canal that connects the throat to the stomach), and into the stomach] every four hours as needed for mild pain rated 1 to 3. 3. Order dated 10/18/22, indicated Tylenol tablet 325 mg, two tablets given via feeding tube every four hours as needed for moderate pain rated 4 to 6. 4. Order dated 10/18/22, indicated Tylenol tablet 500 mg, two tablets given via feeding tube every four hours as needed for severe pain rated 7 to 10. 5. Order dated 10/18/22, indicated Meloxicam (medication to treat swelling, stiffness, and joint pain) tablet 7.5 mg, one tablet given via feeding tube, one time a day for pain management. 6. Order dated 10/19/22, indicated pain assessment and management completed every shift. 7. Order dated 11/21/22, indicated Tylenol 325 mg tablet, two tablets given through the feeding tube, every six hours for management of leg pain. 8. Order dated, 2/7/23, indicated Restorative Nursing Assistant (RNA, staff that provides exercises designed to help with joint movement) to apply extension splints (a firm material used for supporting and immobilizing a bone) on both knees for up to 2.5 hours (2 hours and 30 minutes) once a day, seven times per week. A review of Patient 3's Physician's Order, dated 3/9/23, indicated Tramadol Hydrochloric Acid (HCL, medication that treats moderate to severe pain) 50 mg tablet, one tablet given via feeding tube, two times a day for management of leg pain. During a concurrent observation of Patient 3's room and interview with Patient 3 on 3/16/23, at 2:28 p.m., Patient 3's head of the bed was raised and Patient 3's legs were bent toward the patient's abdomen. Patient 3 was lying in bed with flushed face (reddening of the face) and sweat drops on the patient's forehead. Patient 3 was crying, screaming, tossing (move from side to side) on the bed. Patient 3 was turning his head from left to right with facial grimacing and was restless (inability to rest or relax). Patient 3 had tears coming down his face and the patient's hair was wet. Patient 3 bit his fist and continued to cry and scream. Patient 3 did not respond when the surveyor asked if the patient was in pain. During an observation and concurrent interview on 3/16/23, at 2:30 p.m., Patient 3 had splints on both legs. Restorative Nursing Assistant 1 (RNA 1) stated Patient 3 was grimacing, crying, screaming, biting his fist, moving his upper body on the bed and was restless. RNA 1 stated Patient 3's face looked red, and the patient's head was sweaty. RNA 1 stated Patient 3 had the splints on, and the splints were too painful for Patient 3. RNA 1 stated, "See how he tries to bite his hand from the pain he has." RNA 1 stated she applied the splint on Patient 3 today at 2 p.m. and Patient 3 had to keep the splints on for "four hours." RNA 1 stated Patient 3 could not tolerate wearing the splints. During an interview on 3/16/23, at 2:32 p.m., Patient 4 (Patient 3's roommate) stated Patient 3 cried in pain even at nighttime. Patient 4 stated "I feel so bad for him." During an observation on 3/16/23, at 2:37 p.m., Patient 3 remained restless in bed. Patient 3 was screaming and hitting his face with his left hand. Patient 3 continued to cry and yell. During an observation and concurrent interview on 3/16/23, at 2:38 p.m., LVN 1 and Certified Nurse Assistant 1 (CNA 1) walked in Patient 3's room. CNA 1 repositioned Patient 3 and Patient 3 screamed. LVN 1 stated Patient 3's adult brief (disposable underwear) was dry and clean, and she (LVN 1) administered the pain relief medication (Tylenol) at 2 p.m. LVN 1 stated she would let MD 1 know that Patient 3's pain was not controlled due to Patient 3's grimacing, crying, screaming, sweating, and restlessness. A review of Patient 3's Restorative Nursing Weekly Summary Range of Motion/Exercises, dated 3/16/23, indicated to apply splints on both knees up to 2.5 hours, seven times per week. The summary indicated Patient 3 was cooperative, had pain, and "nursing was notified." A review of Patient 3's Medication Administration Record (MAR), dated 3/16/23, under "Pain Assessment," indicated Patient 3 did not have pain the whole day, during the morning, evening, and night shifts. The MAR indicated Patient 3 did not have any episodes of yelling out, moaning, and groaning during any of the shifts on 3/16/23. The MAR indicated Patient 3 received Tylenol 500 mg, two tablets (1000 mg) on 3/16/23, at 2 p.m. A review of Patient 3's Nurses Note, dated 3/16/23, indicated there was no documentation regarding Patient 3's screening, crying, and yelling due to pain. The note indicated there was no documented evidence LVN 1 notified MD 1 about Patient 3's unrelieved pain after the Tylenol administration on 3/16/23 at 2 p.m. During an interview on 3/17/23, at 5 p.m., the Assistant Director of Nursing (ADON) stated the ways to determine pain for Patient 3 were assessing for grimacing, moaning, crying, and guarding. The ADON stated other signs and symptoms of severe pain included being physically uncomfortable, tensed, yelling, sweating/flushing, and restlessness. The ADON stated the purpose of administering breakthrough pain (a sudden flare up of pain from long standing medical conditions and additional pain medication is needed) medication was to prevent severe pain. The ADON stated staff (in general) needed to administer pain relief medication for breakthrough pain when routine pain medication did not work, or when the next routine pain medication was not due to be given. The ADON stated it was important to accurately assess Patient 3's pain to prevent the patient from feeling uncomfortable. The ADON stated pain reassessment could be done to determine if pain medication was ineffective (not working). During a concurrent interview on 3/17/23, at 5:15 p.m. and a review of Patient 3's Nurse Notes, dated 3/16/23, the ADON stated Patient 3 received Meloxicam and Tramadol for pain management due to contractures. The ADON stated Patient 3 received pain relief medication (Tylenol 1000 mg) on 3/16/23 at 2 p.m. The ADON stated nurses (in general) needed to assess Patient 3 for pain during splint application on Patient 3's contracted legs. The ADON stated the application of the splints could be painful for Patient 3. The ADON stated on 3/16/23, at 2:38 p.m., after LVN 1 witnessed Patient 3 crying and yelling in pain, LVN 1 did not notify MD 1 regarding Patient 3's pain. The ADON reviewed Patient 3's Nurse Notes, dated 3/16/23 and stated there was no documented evidence to indicate LVN 1 notified MD 1 regarding Patient 3's uncontrolled pain during the splint application despite of Tylenol administration on 3/16/23, at 2 p.m. During a concurrent review of Patient 3's Care Plan for Pain, initiated on 10/18/22, and an interview on 3/17/23, at 5:51 p.m., the ADON stated LVN 1 did not implement nursing interventions to respond to Patient 3's complaint of pain or re-evaluate the effectiveness of Patient 3's pain relief medication. A review of the facility's Daily Staffing Sheet, dated 3/17/23, indicated LVN 1 was not scheduled to work on 3/17/23 (LVN 1 was not available to be interviewed). During an interview on 3/17/23, at 6:23 p.m., LVN 2 who was assigned to care for Patient 3, stated signs and symptoms of pain for Patient 3 included facial grimacing, clenched hands, and moaning. LVN 2 stated when Patient 3 was in pain, the pain had to be treated before it reached moderate or severe pain level (rated at 7-10). LVN 2 stated pain could cause mental anguish (mental suffering). During an interview on 3/17/23, at 6:40 p.m., CNA 3 who was assigned to care for Patient 3, stated when Patient 3 yelled he could be frustrated or in pain. CNA 3 stated when Patient 3 was in pain, the patient bit his fist. CNA 3 stated Patient 3 bit his fist to communicate to staff (in general) that he was in pain. During an observation and concurrent interview on 3/17/23, at 6:50 p.m., Patient 3 was screaming, and moaning "help me." LVN 2 asked Patient 3, "Are you in pain?" Patient 3 yelled, "yes, yes, help me." A review of Patient 3's Progress Notes, dated 3/17/2023, indicated Patient 3 had a change of condition (COC, a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains) due to increased pain (no specific location and the pain was not rated). The notes indicated LVN 2 notified MD 1 at 8 p.m. regarding Patient 3's COC. A review of Patient 3's Physician's Order, dated 3/17/28, timed at 8:18 p.m., indicated MD 1 ordered to increase Tramadol HCL, 50 mg, one tablet given via feeding tube, three times a day, for management of leg pain. A review of the facility's undated policy & procedure titled, "Nursing Administration," indicated the policy's subject was pain management. The policy indicated the facility was to provide an environment that assisted each resident who had pain to attain or maintain resident's highest practicable physical, mental, and psychosocial well-being by comprehensively assessing the pain, developing, and implementing a plan. The policy indicated to document residents’ response to pain treatment and assess significant change to ensure pain remains controlled. The policy indicated to monitor pain status, treatment effects and consult the physician for additional interventions if pain is not relieved by currently ordered treatment modalities and comfort measures. The policy indicated if the resident is unable to communicate pain using the rating scale, the clinician will assess behavioral factors that signal pain or discomfort. As a result of the investigation, the CDPH determined that the facility failed to manage Patient 3’s pain by failing to: 1. Ensure LVN 1 assessed Patient 3's leg pain and re-evaluated the effectiveness of the Tylenol administration on 3/16/23, at 2 p.m. as indicated in Patient 3's care plan for pain. 2. Ensure LVN 1 implemented the facility's policy and procedure titled, "Nursing Administration," when LVN 1 did not notify MD 1 regarding Patient 3's uncontrolled/unrelieved leg pain. As a result of this failure, on 3/16/23 and on 3/17/23, Patient 3 experienced physical and emotional distress due to unrelieved and uncontrolled pain on both legs. The above violation, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety or security of Patient 3.