Health inspection·September 16, 2024

§483.25 Quality of Care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices, including but not limited to the following: (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. § 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: (E) Any untoward response or reaction by a patient to a medication or treatment. (G) The facility's inability to obtain or administer, on a prompt and timely basis, drugs, equipment, supplies, or services as prescribed under conditions which present a risk to the health, safety, or security of the patient. 72523. Patient Care Policies and Procedures. Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 7/29/2024, the California Department of Public Health (CDPH) received a complaint indicating a general acute care hospital (GACH) received Resident 3 with bruises all over the body, left rib cage (the bony frame formed by the ribs around the chest) fracture (broken bone) and scabies (parasitic infestation caused by tiny mites that burrow into the skin and lay eggs, causing intense itching and a rash). On 7/30/2024 at 1p.m., an unannounced visit was conduct at the facility to investigate the allegations. The facility failed to: 1). Assess pain levels for Resident 1 on 7/18/2024 and 7/21/2024 during the 7am-3pm shift. 2). Assess pain levels for Resident 3 on 7/15/2024, and 7/16/2024, during the 3pm-11pm, and 11pm-7am shifts. 3). Implement its policy and procedure (P&P) titled, "Administration of Pain Medication," which indicated Licensed Nurses will administer residents' pain medications according to the physician's order. As a result, Residents 1 and 3 experienced pains for extended periods of time. It also caused Resident 3 to have a decline in activities of daily living (ADL), ambulation, with increased heart rate of 127 beats per minute on 7/21/2024, which required transfer to a general acute care hospital (GACH) for evaluation and treatment. 1). Resident 1 was a 65-year-old female, admitted to the facility on 6/13/2024. Resident 1's diagnoses included Stage four (4) pressure ulcer (tissue loss with visible bone, tendon, or muscle) on the sacral (tail bone) and polyneuropathy (weakness and a pins-and-needles sensation, burning pain or loss of sensation to extremities). A review of Resident 1's Minimum Data Set ([MDS] a standardized care screening and assessment tool) dated 6/20/2024, indicated Resident 1 could understand and be understood by others. The MDS indicated Resident 1 was dependent with activities of daily living (ADLs) such as dressing, bathing, bed mobility, and personal hygiene. The MDS indicated Resident 1 had a Stage 4 pressure ulcer. A review of Resident 1's Order Summary Report dated 6/13/2024, indicated to assess Resident 1 for pain before, during and after treatment. The Order Summary Report indicated to assess for pain every shift and chart the intensity of pain using 1-10 numeric scale (1-4 = mild pain), (5-7 = moderate pain), (8-10 = severe pain). A review of Resident 1's Order Summary Report dated 6/17/2024, indicated to administer Norco (strong pain medicine)10/325 milligrams ([mg] unit of measurement), 1 tablet by mouth every four (4) hours as needed for moderate to severe pain. The Order Summary Report indicated to hold Norco if Resident 1 was sleepy or if respiratory rate (breaths per minute) was less than (<) 12 breaths per minute (normal respiratory rate is 12-20 breaths per minute). The Order Summary Report dated 6/17/2024, indicated to separate the administration of Xanax (anxiety medicine) from Norco by at least 4 hours apart. A review of Resident 1's care plan titled, "Acute or chronic pain related to pressure injury (damage to skin and underlying soft tissue) to sacral wound," dated 6/25/2024, indicated staff will administer Norco as ordered, half hour before treatments or care. The interventions indicated staff were to anticipate Resident 1's need for pain relief and respond immediately to any complaint of pain, evaluate the effectiveness of pain interventions, monitor, record, and report to the nurse any signs and symptoms of nonverbal pain, the resident's complaints of pain or requests for pain treatment. The interventions also indicated to notify the physician if interventions were unsuccessful or if the current complaint was a significant change from the resident's experience of pain. A review of Resident 1's Medication Administration Record (MAR) for the month of July 2024, did not indicate Resident 1 was assessed for pain before, during and after treatment, on 7/18/2024 and 7/21/2024. During a concurrent observation and interview on 7/30/2024, at 2:36 p.m., with Resident 1, in Resident 1's room, Resident 1 was observed crying and stating she was unhappy, felt helpless, and frustrated because she could not do anything to get her pain relieved. Resident 1 stated on 7/29/2024, at 5:00 p.m., she (Resident 1) requested for pain medication due to a 10/10 pain on her sacral wound. Resident 1 stated Licensed Vocational Nurse (LVN 1) did not give her pain medication when she requested it. Resident 1 stated LVN 1 told her Norco could not be given because she (Resident 1) had been medicated with Robaxin (a narcotic muscle relaxant) and had to wait until 9:00 p.m., to be medicated with Norco. During an interview on 8/7/2024, at 3:39 p.m., with LVN 1, LVN 1 stated Resident 1 requested Norco on 7/29/2024, at 5 p.m., an hour after she (Resident 1) was administered Robaxin. LVN 1 stated she told Resident 1 that she was not due for Norco till 9:00 p.m. LVN 1 stated the last time Resident 1 received Norco was on 7/29/2024, at 10:30 a.m. LVN 1 stated the Registered Nurse Supervisor (RNS) had advised her not to give Resident 1 Norco and Robaxin together because the Robaxin could cause respiratory depression (very slow or shallow breathing). LVN 1 stated RNS told her (LVN 1) to wait 4 hours (at 9 p.m.) after the Robaxin was administered, before giving Resident 1 Norco. LVN 1 stated, Resident 1's doctor's order did not indicate to hold the Norco when Robaxin was given. LVN 1 stated she followed what the RNS instructed her to do. LVN 1 stated she should have called the Doctor to clarify if Resident 1 could be given Norco or not. LVN 1 stated not managing a resident's pain could result in complications like elevated blood pressure, discomfort, increased pain and could affect resident's quality of life. A review of Resident 1's progress notes dated 7/29/2024, did not indicate LVN 1 addressed Resident 1's complaint of 10/10 to the sacral wound on 7/29/2024 at 5 p.m. and did not indicate any pain relief interventions were provided to Resident 1. During a concurrent phone interview and record review on 8/13/2024, at 2:58 p.m., with the Director of Nursing (DON), Resident 1's MAR and progress notes dated 7/29/2024 were reviewed. The DON stated, on 7/29/2023 at 9:01 p.m., Resident 1 had a pain level of 8/10 (site not indicated), and Norco was administered. The DON stated, per the MAR and progress notes, Resident 1's pain level was not reassessed after the medication (Norco) was administered. The DON stated it was important to reassess pain after medication administration to ensure the medication was effective and to prevent worsening pain condition for the residents. 2). Resident 3 was an 82-year-old male, originally admitted to the facility on 1/25/2022, and re-admitted on 8/4/2024. Resident 3's diagnoses included difficulty walking and fracture (broken bone) of one unspecified rib. A review of Resident 3's MDS dated 7/1/2022, indicated Resident 3 was able to understand and be understood by others. The MDS indicated Resident 3 was independent with eating, and required set up for oral hygiene, shower/bathing. The MDS indicated Resident 3 required partial assistance for toileting hygiene and putting on/taking off footwear. The MDS indicated Resident 3 was incontinent (unable to control) of bowel and bladder. The MDS indicated Resident 3 had a fracture and was not on a pain medication regimen. A review of Resident 3's Order Summary Report dated 8/28/2023, indicated to assess Resident 3 for pain level every shift and chart intensity of pain using 1-10 numeric scale. A review of Resident 3's Order Summary Report dated 2/9/2024, indicated staff were to administer hydrocodone-acetaminophen (medication to treat pain) 5/325 milligrams, 1 tablet by mouth, every 4 hours as needed for moderate pain (5- 7). A review of Resident 3's MAR for the month of July 2024, the following dates did not indicate Resident 3 was assessed for pain: 7/15/2024 evening shift (3pm-11pm) and night shift (11pm-7am). 7/16/2024 day shift (7am-3pm) and night shift. A review of Resident 3's "Change of Condition" (COC) dated 7/18/2024, at 6:44 a.m., indicated on 7/18/2024 (time not specified), Resident 3 had declined in function (unspecified) due to generalized pain (pain level not identified) when moved. The COC did not indicate interventions were provided for Resident 3's generalized pain. A review of Resident 3's COC dated 7/22/2024, at 12:53 p.m., indicated on 7/22/2024 (time not specified), Resident 3 was observed lethargic (sleepy), with facial grimacing (twisting the mouth and face to convey pain, disapproval, or disgust) and yelling "ouch" (expressed sudden pain) when his vital signs were attempted to be taken. The COC indicated Resident 3's heart rate was 127 beats per minute (normal rate is 60-100 beats per minute). The COC did not indicate any pain interventions provided to Resident 3. The COC indicated Resident 3's physician was notified on 7/22/2024, at 12:00 a.m., and Resident 3 was transferred to a GACH on 7/22/2024, at 7:43 a.m. (seven hours after the physician was notified). A review of Resident 3's emergency department (ED) notes, dated 7/22/2024, at 8:16 a.m. indicated Resident 3 had altered level of consciousness (a change in a person's awareness and alertness), and leukocytosis (elevated white cells in the blood occurs when body is fighting inflammation or infection) from the nursing facility. The ED notes indicated a Computerized Tomography ([CT] non-invasive medical imaging procedure that uses X-rays and computers to create detailed pictures of the inside of the body) of the chest, abdomen and pelvis result dated 7/22/2024 at 2:05 p.m. indicated Resident 3 was admitted to trauma service on 7/22/2024, due to a splenic laceration likely caused by adjacent (next to) left posterior (back) 10th rib comminuted fracture (broken bone that has more than two pieces), altered mental status (lethargy), severe sepsis, rapid atrial fibrillation (an irregular, rapid heart rate) and aspiration pneumonia (lung infection that develops after inhalation of food, liquid, or vomit into the lungs). The ED notes indicated Resident 3 received multiple antibiotics due to severe sepsis. A review of Resident 3's care plan titled, "Acute/Chronic Pain related to Left and Right Rib Fracture," dated 8/5/2024, the interventions indicated staff will anticipate the resident's need for pain relief and respond immediately to any complaint of pain, monitor for probable cause of each pain episode and remove/ limit causes where possible, administer analgesia (pain reliever) half hour before treatments or care as ordered. The interventions indicated staff will evaluate the effectiveness of pain interventions every shift, monitor/ record pain characteristic every shift and as needed (PRN) and report any signs and symptoms of nonverbal pain (vocalization of grunting, moaning, yelling out, silence) to nurses. During an observation on 8/8/2024, at 3:42 p.m., with Certified Nurse Assistant (CNA) 8 and CNA 9, both CNA 8 & CNA 9 were observed repositioning Resident 3 while Resident 3 was in bed. Resident 3 was observed groaning, grimacing and yelling (signs of pain). CNA 8 & CNA 9 continued to reposition Resident 3 and did not stop to assess or provide pain interventions to the resident. During a concurrent interview and record review on 8/12/2024, at 9:34 a.m., with the DON, the P&P titled "Administration of Pain Medication" was reviewed. The DON stated according to the P&P, the nurse should have assessed the residents' pain location, level, and type of pain, using the pain numeric scale. The DON stated the nurse should have checked the MAR to see when the last time pain medication was given. The DON stated, if pain medication was not due, the staff should have tried other interventions. The DON stated if the medication was not effective, the staff should have contacted the doctor to obtain orders. The DON stated, if the resident needed pain management right away, licensed staff should have given the pain medication immediately. The DON stated, not providing pain medication immediately could lead to a seizure (burst of uncontrolled electrical activity in the brain that cause uncontrollable movement) and could be very uncomfortable for the resident physically and emotionally. During a concurrent phone interview and record review on 8/13/2024, at 2:58 p.m., with the DON, Resident 3's MAR, COC, and progress notes dated 7/18/2024, 7/22/2024, and 7/29/2024, were reviewed. The DON stated Resident 3's COC and progress notes dated 7/18/2024, did not indicate assessment was done regarding the resident's complaint of generalized pain (pain level not identified). The DON stated the progress notes did not indicate pain medication was administered on 7/18/2024, when Resident 3 complained of generalized pain, and on 7/22/2024 (daytime, time not specified), when Resident 3 had a pain level of 9/10 (site not indicated). The DON stated Resident 3 should have received either acetaminophen 325 mg (pain reliever) for mild pain or Norco 5/325 mg for moderate pain. The DON stated the licensed nurse did not provide interventions for Resident 3's pain. The DON stated the unrelieved pain could have caused emotional distress and could affect Resident 3's ADLs. The DON stated the pain caused Resident 3 to be afraid to move or do anything. During a phone interview on 8/13/2024, at 3:46 p.m., with CNA 8, CNA 8 stated on 8/8/2024, at 3:42 p.m., when Resident 3 groaned, grimaced, and yelled when CNA 8 and CNA 9 were repositioning Resident 3, Resident 3 was in severe pain. CNA 8 stated they should have stopped and notified a LVN for medication. CNA 8 stated the LVN (unidentified) had already been in Resident 3's room, and CNA 8 did not think the need to no