Health inspection·January 19, 2024

F697 Code of Federal Regulations, Title 42, Section §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.

F710 Code of Federal Regulations, Title 42, Section §483.30(a) Physician Supervision. The facility must ensure that— §483.30(a)(1) The medical care of each resident is supervised by a physician; §483.30(a)(2) Another physician supervises the medical care of residents when their attending physician is unavailable. On 12/8/2023 at 9 a.m., The California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a complaint regarding quality care and physician services. As a result of the investigation, the Department determined the facility failed to provide appropriate pain management for Resident 4 who was diagnosed with low back pain, by failing to: 1. Ensure Licensed Vocational Nurses (LVN) 3 and 4 called Medical Doctor (MD) 1 to obtain a new order when Resident 4 experienced lower back pain ranging from 8 to 10 out of 10 (1 to 3 being mild pain; 4 to 6 being moderate pain; 7 to 9 being severe pain, and 10 being the worst pain imaginable/very severe pain) on 10/18/2023, at 4 am. 2. Ensure MD 1 and the Medical Director (MDD) were reachable by phone to authorize the pharmacy to deliver Norco (Hydrocodone-acetaminophen, medication used to treat moderate pain) 5-325 milligram (mg, unit of measurement) per Resident 4’s Order Listing Report (OLR) when contacted by facility’s nursing staff. As a result of these failures, on 10/18/2023, Resident 4 endured 12 hours of severe lower back pain (from 10/18/2023, at 4:25 am to 10/18/2034, at 4:09 pm) before Resident 4 was transferred to General Acute Care Hospital (GACH) 1 and received Morphine (narcotic medication used to treat severe pain) for pain relief. A review of Resident 4's Admission Record (AR) indicated the facility admitted a 60 years old female, on 10/17/2023 with diagnoses including unspecified low back pain, muscle wasting and atrophy, and abnormalities of gait and mobility. A review of Resident 4's Emergency Room Physician Note from GACH 1, dated 10/18/2023 at 4:06 pm indicated Resident 4 was diagnosed with acute exacerbation of chronic lower back pain. Resident 4 received acetaminophen (pain medication) 1000 mg by mouth on 10/18/2023, at 4:09 pm. The note indicated Resident 4 received morphine sulfate injection 4 mg by intra-muscular injection on 10/18/2023, at 4:10 pm. A review of Resident 4's Minimum Data Set (MDS- a standardized resident assessment and care screening tool), dated 10/26/2023 indicated Resident 4 had intact cognition. The MDS indicated Resident 4 required partial/moderate assistance with eating, oral hygiene, and personal hygiene. The MDS indicated Resident 4 was dependent with toileting hygiene and showering/bathing self. During an interview on 12/8/2023 at 10:55 am, with Resident 4, Resident 4 stated on 10/18/2023, Resident 4's pain was at an eight out of 10 on the pain scale. Resident 4 stated on 10/18/2023, at 4 am, Resident 4 received 1 dose of Norco. Resident 4 stated when the pain returned (unknown time) Resident 4 requested for Resident 4's next dose of pain medication and the nurse (unable to identify) told Resident 4 the medication was "not ready.” Resident 4 stated Resident 4 "requested pain medication all morning." Resident 4 stated Resident 4's pain was unmanaged (not relief) and no one in the facility helped Resident 4 with pain relief. Resident 4 stated Resident 4 called 9-1-1 Resident 4 was transported to GACH 1 at 2 pm for pain management. Resident 4 stated Resident 4 was given Morphine at GACH 1 on 10/18/2023, at 4:09 pm (12 hours later). Resident 4 stated Resident felt worthless, awful, and about to die when the facility failed to address Resident 4's pain management concerns. During a concurrent interview and record review on 12/8/2023 at 12:27 pm, with the MDS Nurse (MDSN), Resident 4's OLR, dated October 2023, Progress Note, dated 10/18/2023 at 7:38 am, and MAR, dated October 2023 were reviewed. The MDSN stated Resident 4's OLR indicated Resident 4 was ordered Norco 5-325 mg, give 1 tablet every four hours (q4h) as needed for moderate pain on 10/17/2023 by MD 1. The MDSN stated LVN 3 indicated in Resident 4’s Progress Note that Norco dose was taken from the facility's emergency kit (e-kit- medication kit used when pharmacy has not delivered consistent doses) on 10/18/2023 at 4:25 am. The MDSN stated Resident 4's MAR indicated Resident 4 received Norco 5-325 mg for 10 of 10 pain on 10/18/2023 at 4:25 am. The MDSN stated 10 of 10 pain was considered the worst pain. The MDSN stated Resident 4's Norco 5-325 mg prescribed medication was not appropriate to treat Resident 4's severe pain. The MDSN stated LVN 4 did not contact MD 1 to report to MD 1 and request for a stronger pain medication to treat severe pain. During a concurrent interview and record review on 12/8/2023 at 12:52 pm, with the Director of Nursing (DON), Resident 4's Progress Notes, dated 10/18/2023 were reviewed. The DON stated Resident 4's notes did not indicate staff attempted to inform MD 1 of Resident 4's severe pain level. The DON stated Resident 4's pain level was at 8 out of 10 on 10/18/2023, at 12:40 pm. The DON stated 8 out of 10 was considered severe pain. The DON stated Norco was not intended to treat severe pain and was not an appropriate medication for Resident 4. The DON stated being in severe pain could affect Resident 4's "cognition, ability to make decisions, answer questions, and function." The DON stated Resident 4 called 9-1-1 and was transferred to GACH 1 for pain management. The DON stated Norco 5-325 mg was a controlled substance (high potential for abuse, with use potentially leading to severe psychological or physical dependence), and it required MD 1 to contact the pharmacist to authorize the delivery of Norco, as a safety measure. The DON stated Resident 4 was a newly admitted resident and the Norco order was pending an authorization by MD 1 for medication delivery. A review of Resident 4's Progress Note, dated 10/18/23, timed 2:55 pm indicated Resident 4 had an order to transfer Resident 4 to GACH 1 for an evaluation and management of severe pain. The note indicated transportation services were arranged for Resident 4 to be transferred to GACH 1. During a telephone interview on 12/18/2023 at 2:46 pm, with LVN 3, LVN 3 stated Resident 4 called 9-1-1 because Resident 4 "was in so much pain." LVN 3 stated LVN 3 did not attempt to reach MD 1 to inform MD 1 of Resident 4's severe pain. LVN 3 stated LVN 3 attempted to reach MD 1 to get Norco authorized for delivery for Resident 4, but LVN 3 did not get a call back from MD 1 nor MDD. During a telephone interview on 12/8/2023 at 3:29 pm, with the MDD, the MDD stated part of the MDD's job was to be available if the primary physicians were not available. The MDD stated the MDD worked to solve problems related to medical issues at the facility. The MDD stated the MDD was on-call and available 24 hours a day, seven days a week. During an interview on 12/8/2023 at 4:54 pm, with the DON, the DON stated Resident 4 was experiencing pain for 12 hours without receiving appropriate pain medication. The DON stated pain was subjective and it was the nursing staff’ responsibility to maintain Resident 4's comfort level and attempt to inform MD 1 when Resident 4 was in pain. The DON stated Resident 4's pain was not being managed appropriately with the medication ordered (Norco). The DON stated, "being in that much pain could affect a resident's mood, cause anger, frustration, and lead to depression." During a review of the facility's PP titled, "Guidelines for Notifying Physicians of Clinical Problems," dated September 2017 indicated the guidelines were intended to help ensure that medical care problems were communicated to the medical staff in a timely, efficient, and effective manner and that all significant changes in a resident/patient status are assessed and documented in the medical record. The PP indicated the practitioner was responsible for responding in a timely manner to calls, especially regarding immediate notification problems. The PP indicated immediate notification (acute) problems included the symptoms, and/or signs such as sudden onset or a marked changed (for example, much more severe or frequent) compared to usual or baseline and are unrelieved by measures which had already been prescribed or attempted. During a review of the facility's PP titled, "Pain Assessment and Management," revised October 2022 indicated the purpose was to help staff identify pain in the resident, and to develop interventions that were consistent with the resident's goals and needs that addressed the underlying causes of pain. The PP indicated pain management was defined as the process of alleviating the resident's pain abased on his or her clinical condition and established treatment goals. The PP indicated acute pain (or significant worsening of chronic pain) should be assessed every 30 minutes to 60 minutes after the onset and reassessed as indicated until relief is obtained. The PP indicated if pain had not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as indicated. The PP indicated to report the following information to the physician or other practitioner: significant changes in the level of the resident's pain and prolonged, unrelieved pain despite care plan interventions. As a result of the investigation, the Department determined the facility failed to provide appropriate pain management for Resident 1 who was diagnosed with low back pain, by failing to: 1. Ensure LVN 3 and 4 called MD 1 to obtain a new order when Resident 4 experienced lower back pain ranging from 8 to 10 out of 10 on 10/18/2023, at 4 am. 2. Ensure MD 1 and the MDD were reachable by phone to authorize the pharmacy to deliver Norco 5-325 mg per Resident 4's OLR when contacted by the facility staff. As a result of these failures, on 10/18/2023, Resident 4 endured 12 hours of severe lower back pain before Resident 4 was transferred to GACH 1 and received Morphine for pain relief. The above violations had a direct or immediate relationship to the health, safety, or security of Resident 4.