Health inspection·July 5, 2024

F697 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. 22 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. 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. (c) The time and dose of the drug or treatment administered to the patient shall be recorded in the patient's individual medication record by the person who administers the drug or treatment. Recording shall include the date, the time and the dosage of the medication or type of the treatment. Initials may be used, provided that the signature of the person administering the medication or treatment is also recorded on the medication or treatment record. 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. 22 CCR § 72543. Patients' Health Records. (a) Records shall be permanent, either typewritten or legibly written in ink, be capable of being photocopied and shall be kept on all patients admitted or accepted for care. All required records, either originals or accurate reproductions thereof, shall be maintained in such form as to be legible and readily available upon the request of the attending licensed healthcare practitioner acting within the scope of his or her professional licensure, the facility staff or any authorized officer, agent, or employee of either, or any other person authorized by law to make such request. On 5/20/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility during the Recertification survey. As a result of the investigation, CDPH determined the facility failed to: 1.Administer Tylenol pain medication (used to relieve minor pain) for approximately 66 doses, per the Physician's Order on 5/9/2024. 2.Administer Percocet pain medication (a narcotic combination of Oxycodone and Acetaminophen used to treat moderate to severe pain), per the Physician's Order on 5/11/2024 for Resident 1's pain. 3. Evaluate the effectiveness of the Percocet pain medication administered to Resident 1 on 5/11/2024, in accordance with professional standards of care. 4. Notify the physician that Resident 1's pain located in the legs, arms and abdomen, was not being relieved, and experienced non-effective pain management interventions, per the At Risk for Pain care plan. 5. Implement the facility's policy and procedure (P&P) titled, "Change in a Resident's Condition and Status," dated 9/2023, when facility staff did not notify the resident's attending physician or physician on call, within twenty-four (24) hours of change occurring in the resident's medical / mental condition or status. 6. Identify when Resident 1's pain could be anticipated, per the At Risk for Pain care plan and consistent with the care plan goals. 7. Legibly write or document Resident 1's health record, including the Pain Assessment Record. 8. Implement the facility's P&P titled, "Pain-Clinical Protocol," dated 9/2023, when facility staff did not evaluate and report the resident's use of standing and when necessary or as needed (PRN) analgesics. As a result, Resident 1 continuously experienced severe, unrelieved pain from 5/11 to 5/22/2024, for a total of 11 days, as the resident was unable to walk due to leg pain. Resident 1's symptoms were not relieved to the extent possible, as the resident felt her pain was stressful as she could not perform daily activities, diminishing the resident's quality of life. A review of the Admission Record indicated Resident 1 was admitted to the facility on 5/9/2024, with diagnoses including unspecified cirrhosis (a disease condition that scars and damages the liver), anxiety disorder, and abnormalities of gait and mobility. A review of the Physician's Order dated 5/9/2024 indicated the following orders: -Percocet one tablet 5-325 milligrams (mg, a unit of measurement), every six hours as needed for severe pain, rated at 7 out of 10 using pain rating scale 0-10 (a numeric pain scale, zero indicating no pain and 10 indicating the worst possible pain) for three months. -Acetaminophen (Tylenol, a medication that treat minor pain), one tablet 650 mg, every four hours as needed for mild pain rated 1-3. A review of Resident 1's History and Physical dated 5/10/2024, indicated the resident had the capacity to understand, make decisions, and was alert and oriented times four. According to a review of the Medication Administration Record, dated from 5/9 - 5/23/2024, Resident 1 did not receive any of the Physician's Ordered Tylenol for mild pain as needed. A review of the Pain Assessment Record dated from 5/10 - 5/20/2024 indicated Resident 1's pain rating was illegible for 16 of the 39 times documented. A review of the Care Plan dated 5/13/2024 indicated Resident 1 was At Risk for Acute (sudden) or Chronic (persisting for a long time) Pain. The care plan goal indicated Resident 1 would not have interruption in normal activities due to pain and would verbalize adequate relief of pain. The care plan interventions indicated to anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Monitor, record, and report to nurse any signs and symptoms of non-verbal pain, changes in breathing, vocalizations (moaning), mood / behavior changes (face [grimacing]), the resident's complaints of pain or requests for pain treatment. The care plan interventions further indicated to notify the resident's physician if interventions were unsuccessful or if current complaint was a significant change from resident's experience of pain. During an observation on 5/20/2024 at 10 AM, Resident 1 was lying in bed on her left side, moaning. Resident 1 was observed with facial grimacing and taking long, deep breaths. During a concurrent interview Resident 1 stated, "I need pain medication. It takes hours to get my pain medications. My legs and arms hurt." Resident 1 stated she was having pain since admission (5/9/2024), and the delays to receive pain medication were reported to the head staff, but the resident was unable to recall any staff names. During an observation, on 5/21/2024 at 11:29 AM, Resident 1 was lying in bed on her left side, moaning. Resident 1 was observed with facial grimacing and taking long, deep breaths. During a concurrent interview, Resident 1 stated she was feeling pain in both hands, both legs, and abdomen. Resident 1 stated the pain was stressful as she was unable to walk with her walker as usual, because of the leg pain. On 5/21/2024 at 11:35 AM, during an interview, Licensed Vocational Nurse (LVN) 6 stated Resident 1 had the Percocet pain medication ordered to give every six hours, but the resident asked for medication at least every two to three hours. LVN 6 stated the resident's pain was not controlled and had not been reported to the physician. LVN 6 stated this concern had not been discussed with the Interdisciplinary Team (IDT, a team of professionals from various fields who work together toward the goals of the resident). When asked why she (LVN 6) did not medicate Resident 1 with pain medication, LVN 6 stated, "It was not due." During an observation on 5/22/2024 at 9:57 AM, Resident 1 was lying in bed on her left side, moaning. Resident 1 was observed with facial grimacing and taking long, deep breaths. During a concurrent interview, Resident 1 stated, "I am in a lot of pain in my hands and legs. I am waiting for pain medication. My legs are numb. I cannot walk. My stomach hurts." During an interview on 5/22/2024 at 10 AM, LVN 3 stated Resident 1 asked for pain medication at least once or twice a day. LVN 3 stated the resident could decline psychosocially (inter and behavior) and decline from participating with in activities if pain was not controlled. During a concurrent review of Resident 1's Pain Assessment Record, LVN 3 stated he agreed the dates from 5/10 - 5/21/2024 were illegible, and he could not decipher it. LVN 3 stated he could not identify the initials of the licensed nurse documenting and that Resident 1's MAR for May 2024 did not correlate with the Pain Assessment Record, as the pain assessment record dated 5/12/2024 indicated zero, but the MAR for same date indicated 8 out of 10. During an interview on 5/22/2024 at 10:30 AM, LVN 3 stated Resident 1's physician was called and updated on the resident's pain status. During an observation on 5/23/2024 at 8:30 AM, Resident 1 was lying in bed on her left side, moaning. Resident 1 was observed with facial grimacing and taking long, deep breaths. During a concurrent interview Resident 1 stated, "I am still in pain in my legs, it is affecting my mobility. I like to walk with my walker, but I'm unable to do it more than a couple of steps because of the pain." On 5/23/2024 at 8:35 AM, during an interview, LVN 3 stated Resident 1 was given Percocet for pain on average of two or three times a day, out of a total four doses ordered for the 24 hours. During a concurrent record review of Resident 1's Pain Assessment Record and the MAR for May 2024, LVN 3 stated when Percocet was administered to Resident 1 from 5/11 to 5/15/2024, on 5/17/2024, and from 5/19 to 5/22/2024, Resident 1's pain was rated an 8 out of 10. During a concurrent interview and record review on 5/23/2024 at 8:55 AM with LVN 7, Resident 1's Pain Assessment Record was reviewed. LVN 7 stated Resident 1 was not getting adequate pain relief or adequate pain medication and this concern was not reported to the resident's physician. LVN 7 stated there was no pain consultation initiated and that the resident was likely to decline if the pain was not managed. During an interview on 5/23/2024 at 1:15 PM the Director of Nursing (DON) stated, the licensed nurses were expected to notify residents' general changes in condition to the charge nurses and physicians. The DON stated Resident 1 could decline physically and psychosocially if pain was not under control. The DON acknowledged Resident 1's Pain Assessment Record was illegible. During a telephone interview on 5/23/2024 at 3 PM, Resident 1's physician (MD) 1 stated, "The resident has neuropathic pain (a condition that affects the nerves in the body) and the facility staff did not notify me of the resident's pain status." MD 1 stated, "The resident can benefit from better pain management." A review of the facility's policy and procedure titled, "Change in a Resident's Condition and Status," dated 9/2023, indicated the nurse would notify the resident's attending physician or physician on call, except in medical emergencies, notifications would be made within twenty-four (24) hours of change occurring in the resident's medical / mental condition or status. A review of the facility's policy and procedure titled, "Pain-Clinical Protocol," dated 9/2023 indicated the staff would evaluate and report the resident's use of standing and when necessary or as needed (PRN) analgesics (a medication to relieve pain). If the resident's pain was complex or not responding to standard interventions, the attending physician may consider additional consultative support. The facility failed to: 1.Administer Tylenol pain medication (used to relieve minor pain) for approximately 66 doses, per the Physician's Order on 5/9/2024. 2.Administer Percocet pain medication (a narcotic combination of Oxycodone and Acetaminophen used to treat moderate to severe pain), per the Physician's Order on 5/11/2024 for Resident 1's pain. 3. Evaluate the effectiveness of the Percocet pain medication administered to Resident 1 on 5/11/2024, in accordance with professional standards of care. 4. Notify the physician that Resident 1's pain located in the legs, arms and abdomen, was not being relieved, and experienced non-effective pain management interventions, per the At Risk for Pain care plan. 5. Implement the facility's policy and procedure (P&P) titled, "Change in a Resident's Condition and Status," dated 9/2023, when facility staff did not notify the resident's attending physician or physician on call, within twenty-four (24) hours of change occurring in the resident's medical / mental condition or status. 6. Identify when Resident 1's pain could be anticipated, per the At Risk for Pain care plan and consistent with the care plan goals. 7. Legibly write or document Resident 1's health record, including the Pain Assessment Record. 8. Implement the facility's P&P titled, "Pain-Clinical Protocol," dated 9/2023, when facility staff did not evaluate and report the resident's use of standing and when necessary or as needed (PRN) analgesics. As a result, Resident 1 continuously experienced severe, unrelieved pain from 5/11 to 5/22/2024, for a total of 11 days, as the resident was unable to walk due to leg pain. Resident 1's symptoms were not relieved to the extent possible, as the resident felt her pain was stressful as she could not perform daily activities, diminishing the resident's quality of life. The above violations presented an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1.