Health inspection·March 11, 2025

F697- §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. T22 Section 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. T22 Section 72311. 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. (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. T22 Section 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 2/4/2025, the California Department of Public Health (CDPH) conducted an unannounced annual recertification survey. As a result of the investigation, the CDPH determined the facility failed to provide pain management for Resident 140 as indicated in Resident 140's care plan for pain by falling to: 1) Provide non-pharmacological interventions/measures for pain. 2) Notify Resident 140's Medical Doctor (MD) when Resident 140’s pain was uncontrolled with the current pain medication/pain management. These failures resulted in Resident 140 experienced severe pain on the abdomen and had to wait for more than one hour to receive pain medication. A review of Resident 140's AR indicated the facility admitted Resident 140, a 69-year-old male on 1/29/25 with diagnoses that included sepsis, gastric ulcer with perforation and encounter for surgical aftercare following surgery on the digestive system. A review of Resident 140's Medication Administration Record (MAR) dated 1/1/25-1/31/25 indicated Resident 140 had a pain level between 8-9/10 (0=no pain and 10 severe pain) on 1/29/25, 1/30/25, and 1/31/25. A review of Resident 140's History & Physical dated 1/29/25 indicated Resident 140 had the capacity to understand and make decisions. A review of Resident 140's Progress Note dated 1/30/25 indicated Resident 140’s left upper abdomen had intra-abdominal drainage tube due to perforated bowel. A review of Resident 140's At Risk for Pain Care Plan initiated on 1/30/25 indicated for nursing staff to provide non-pharmacological measures for pain such as a gentle range of motion, meditation, positioning, massage and music, document response and report uncontrolled pain to physician for further evaluation and treatment. A review of Resident 140's MAR dated 2/1/25 - 2/28/25 indicated Resident 140 had a pain level between 8-9/10 on 2/3/25, 2/4/25, and 2/5/25. A review of Resident 140's Physician Orders (PO) dated 2/5/25 indicated Gabapentin Oral Capsule 300mg, two capsules, by mouth, every eight hours for neuropathic pain management; Oxycodone Hydrochloride Oral tablet 5mg, three tablets, by mouth, every four hours as needed for pain management; Acetaminophen Oral Tablet 325mg, two tablets, by mouth, every six hours as needed for mild pain 1-3/10. Resident 140's PO dated 1/29/25 indicated to monitor pain level every shift using numerical rating scale (NRS): no pain= 0/10, mild pain =1-3/10, moderate pain = 4-6/10, severe pain 7-10/10. If pain was identified, licensed staff needed to provide non-pharmacological interventions and record pain level for Resident 140. During an interview on 2/5/25 at 10:44 a.m., Resident 140 complained of pain level 10/10 in the left side of Resident 140's abdomen. Resident 140 stated the pain got so bad that it hurt when Resident 140 breathed. Resident 140 stated Resident 140 was concerned about not being given pain medication each day between 8:45 a.m. and 12:45 p.m. During a concurrent interview and record review on 2/6/25 at 11:37 a.m., with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated at 7 a.m. Resident 140 complained of pain and Resident 140's pain medication was not due until 8:45 a.m. LVN 3 stated Resident 140 stated "it was hurting so bad” when Resident 140 started breathing. LVN 3 stated LVN 3 did not document Resident 40's complaint in Resident 140's medical record. LVN 3 stated LVN 3 explained to Resident 140 that Resident 140's pain medication was not due until 8:45 a.m. and LVN 3 provided Resident 140's pain medication time/medication schedule to Resident 140. LVN 3 stated Resident 140 continued to complain of pain level 9/10 in Resident 140's left abdomen. LVN 3 stated about one hour and a half later, Resident 140 continued to complain of 9/10 pain in the left abdomen. Resident 140's Progress Notes were review with LVN 3 and there was no documentation that non-pharmacological interventions (NPIs) were provided to Resident 140. LVN 3 stated non-pharmacological interventions were important because Oxycodone was a narcotic and there was a risk for residents to develop dependence to opioids. LVN 3 stated, sometimes the residents were stressed out when they were in a different place and not at their home, so distraction could help to decrease the resident’s pain. LVN 3 stated it was important to provide NPIs to Resident 140 and document in Resident 140's medical record. A record review of the facility's undated Policy & Procedure (P&P) titled, "Psychotherapeutic Drug Management," indicated the facility will utilize individualized, non-pharmacological approaches to care (e.g., purposeful and meaningful activities). Meaningful activities are those that address the resident's customary routines, interest, preferences, and choices to enhance the resident's well-being. A review of the facility's undated P&P titled, "Pain Management," indicated the facility was responsible for helping the resident attain or maintain their highest level of well-being while working to prevent or manage the resident's pain. Nursing Staff will also utilize non-pharmacological interventions by adjusting the resident's environment to reduce pain. The Licensed Nurse will document resident's pain and response to interventions in the medical record on the weekly summary and as indicated in the progress notes. The facility failed to provide pain management for Resident 140 as indicated in Resident 140's care plan for pain by falling to: 1) Provide non-pharmacological interventions/measures for pain. 2) Notify Resident 140's MD when Resident 140’s pain was uncontrolled with the current pain medication/pain management. These failures resulted in Resident 140 experienced severe pain on the abdomen and had to wait for more than one hour to receive pain medication. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 140.