Health inspection·June 16, 2022

F580 § 483.10 (g) (14) Notification of Changes (i) A facility must immediately inform the patient; consult with the patient’s physician; and notify, consistent with his or her authority, the patient representative(s) when there is, (B) A significant change in the patient’s physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment

F697 §483.25(k) Pain Management. The facility must ensure that pain management is provided to patients who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the patients’ goals and preferences. The facility failed to ensure Patient 1 who had a history of fall that required a laminectomy (a surgical procedure that removes a portion of a vertebra called the lamina, which is the roof of the spinal canal) on 11/28/21, received adequate pain management and be relieved of the patient’s surgical pain by ensuring: 1. The facility notified Patient 1’s physician and administered medication prescribed for Patient 1’s complaints of unrelieved moderate to severe surgical pain to the back from 12/2/21 to 12/3/21 (14 hours). 2. The facility notified the attending physician the need to call and coordinate with the facility pharmacy to authorize Norco (Norco: a narcotic [a drug that affects mood and behavior] pain medication) on the evening of 12/2/2021 to the early morning of 12/3/2021. 3. The facility assessed Patient 1’s pain level for intensity, pattern, location, frequency and duration of surgical pain to the back from 12/2/21 to 12/3/21 (14 hours). Patient 1's pain level was 10/10 (pain level from 1 to 3 (mild pain); 4 to 6 (moderate pain) and 7 to 10 (severe pain) with 10 being the highest level of pain), during an observation on 12/3/21 at 10:20 AM. 4. The facility's policy and procedure on Pain Management, was implemented by ensuring the patient’s pain was alleviated to a level that is acceptable to the patient while minimizing negative effects on the resident to the extent possible. Patient 1 received pain medication for severe pain, on 12/3/21 at 11:30 AM (after 14 hours). As a result, Patient 1 experienced unrelieved and excruciating severe pain from 12/2/21 to 12/3/21, for 14 hours. On 12/3/21 at 10:05 AM, an unannounced visit was conducted at the facility for a complaint regarding quality of care. During a facility tour on 12/3/21 at 10:18 AM, Patient 1's call light was observed on, with a flashing light by the patient's door and the auditory alarm was heard across the facility hallway (to alert staff to patient's call lights). During the observation, more than one facility staff were observed walking past the hallway, past Patient 1's room and did not address Patient 1's flashing call light. During a concurrent observation in Patient 1's room, and interview on 12/3/21 at 10:20 AM, Patient 1 was observed lying in bed with the call light in the patient’s right hand. Patient 1 was wearing a hospital gown and a back brace. Patient 1 stated he was admitted to the facility the other evening (12/2/21) at approximately 9 PM from a general acute care hospital (GACH). Patient 1 stated he was wearing a back brace because he fell from home. Patient 1 stated he had been calling for the facility staff by using the call light, but the facility staff had not come to his room. During the observation, Patient 1 was observed with facial grimacing (a facial expression usually of disgust, disapproval, or pain), his body was stiff, while holding the call light tightly in his right hand. Patient 1 stated LVN 2 gave him Tylenol (medication used to treat mild pain), which was ineffective. Patient 1 stated on a pain scale of one to ten, Patient 1's pain level was a 10. Patient 1 stated his pain level at that time was "excruciating" (intensely painful). During a subsequent observation and interview in the Patient 1's room, on 12/3/21 at 10:29 AM, the Director of Nursing (DON) informed Patient 1 that Norco (hydrocodone/acetaminophen- narcotic, controlled substance, combination of two pain medications that help treat moderate to severe pain) 7.5 milligrams (mg: a unit of measurement) was administered "not too long ago" and that the DON would call Physician 1 to check if additional pain medications could be administered. During the interview, Patient 1 informed the DON, "It hurts so bad." A review of Patient 1's Medication Administration Record (MAR) for December 2021 for Tylenol tab 325 mg, give two tablets by mouth every four hours as needed for mild pain (1 to 3), with an order start date of 12/2/21 timed at 9:15 PM. The MAR indicated Tylenol had been administered for the 11 PM to 7 AM shift on 12/3/21. The MAR indicated Patient 1's pain level was 4 (moderate pain) out of 10. A review of Patient 1's MAR for December 2021 for Norco Tablet 7.5-325 mg, give one tablet PO every four hours as needed for moderate pain (4 to 6 pain level), with an order start date of 12/2/21 timed at 9:15 PM. The MAR indicated Norco 7.5-325 mg was not administered on 12/2/21 or 12/3/21. A review of Patient 1's Medication Administration Record (MAR) for December 2021, indicated Norco Tablet 10-325 milligrams (mg; unit of measurement), give one tablet by mouth every four hours as needed for severe pain (7 to 10 pain level) with an order start date of 12/2/21 timed at 9:15 PM. The MAR indicated Norco 10-325 mg was not administered until the next day dated 12/3/21 timed at 11:30 AM for Patient 1's 10/10 pain (severe pain). A review of the facility's Emergency Kit Pharmacy Log indicated Patient 1 received Norco 10-325 mg, one tablet on 12/3/21 timed at 11:30 AM. A review of Patient 1’s General Acute Care Hospital (GACH) Discharge Summary dated 12/2/21 timed at 4:06 PM indicated Patient 1 was treated the GACH Emergency Room (ER) on 11/27/21, prior to admission to the facility. The GACH Discharge Summary indicated Patient 1 had severe back and hip pain with lower extremity numbness and weakness after a fall at home. The Discharge Summary indicated Patient 1 was found to have impingement of cauda equina (occurs when the nerve roots in the lumbar spine are compressed, cutting off sensation and movement) and was admitted to the intensive care unit (ICU specialized hospital wards that provide treatment and monitoring for people who are very ill) prior to surgery. The GACH Discharge Summary indicated Patient 1 underwent a laminectomy (a surgical procedure that removes a portion of a vertebra called the lamina, which is the roof of the spinal canal) and decompression (relieve pressure on the spinal cord or nerves) on 11/28/21. The Discharge Summary indicated Patient 1 was having a pain level of 8 to 10 out of 10, with Norco added as well as Gabapentin (a medication used to treat certain seizures, and nerve pain). A review of Patient 1' s facility Admission Record indicated Patient 1 was admitted to the facility on 12/2/21 with diagnoses that included cerebral palsy (group of disorders that affect the movement and muscle tone or posture), surgical aftercare following surgery on the nervous system, and fusion of the spine (surgical procedure used to correct problems with the small bones in the spine). A review of Patient 1's Clinical Admission Evaluation dated 12/2/21, indicated Patient 1 was admitted to the facility on 12/2/21, due to status post (an event, that a patient has experienced previously) laminectomy and status post fall at home. A review of Patient 1's Physician Orders dated 12/2/21 timed at 9:08 PM, indicated an order of Tylenol Tablet 325 mg, give two tablets by mouth every four hours as needed for mild pain (pain level from 1 to 3). A review of Patient 1's Physician Orders dated 12/2/21 timed at 9:09 PM, indicated to administer Norco (a narcotic [a drug that affects mood and behavior] pain medication) tablet 7.5-325 mg, give one tablet by mouth every four hours as needed for moderate to severe pain (pain level from 4 to 6). A review of Patient 1's Physician Orders dated 12/2/21 timed at 9:09 PM indicated Norco 10-325 mg tablet, give one tablet by mouth every 4 hours as needed for severe pain level from 7 to 10). A review of Patient 1's Initial History and Physical (H & P) dated 12/3/21 indicated Patient 1 had the capacity to understand and make decisions. The H & P indicated Patient 1 complains of pain and relieved by Norco. The H & P indicated under "general pain," Norco and Gabapentin was ordered. A review of Patient 1's Nurses Progress Note dated 12/3/21 timed at 7:15 AM, indicated Patient 1 was asleep "on and off during the night" and complained of pain to the back at 1:30 AM. The Nurses Progress Note indicated that Tylenol was administered with minimal efficacy after one hour. The Nurses Progress Note indicated Norco was unavailable because Patient 1 was newly admitted to the facility, and the facility's Emergency (E) kit (contain a small quantity of medications that can be dispensed when pharmacy services are not available) could not be opened because Patient 1's attending physician (Physician 1) had not confirmed authorization of Norco. The Nurses Progress Note indicated that Licensed Vocational Nurse (LVN) 2 called the pharmacy to obtain PRN (as needed) Norco from the E-kit and was informed by the facility's pharmacist that PRN Norco had not been authorized by Physician 1, therefore Norco could not be administered. The Nurses Progress Note did not indicate follow up calls to Physician 1 to notify Patient 1's complaints of unrelieved pain on 12/3/21 at 1:30 AM onwards. During an interview on 12/3/21 at 10:30 AM, Licensed Vocational Nurse (LVN) 1 (AM shift) stated Patient 1 had received two Tylenol 325 mg tablets for pain during the previous night shift, because the facility's pharmacy did not authorize the opening of the E-kit for the licensed nurses to get Norco. LVN 1 stated Patient 1 did not get any other pain medications (aside from Tylenol) since LVN 1 started the morning shift at 7 AM. LVN 1 stated she was aware of Patient 1's complaints of pain but was still awaiting authorization from Physician 1 to administer the Norco. During an interview on 12/3/21 at 11:36 AM, Certified Nurse Assistant (CNA) 1 stated that since she had arrived at the facility during the morning shift (12/3/21) at 7 AM, CNA 1 observed Patient 1 had been complaining repeatedly of back pain. CNA 1 stated he had informed LVN 1. During an interview on 12/3/21 at 11:52 AM, in the presence of the Administrator, the DON stated patient's pain must be addressed and managed. During a concurrent interview and record review of Patient 1's MAR on 12/3/21 at 10:31 AM, in the presence of LVN 1, the DON stated Tylenol was to be administered for mild pain between 1 to 3. The MAR indicated Patient 1 had a documented pain score of 4 out of 10 pain, and Tylenol pain medication was administered (night shift of 12/2/21). The MAR did not indicate that Norco was given to Patient 1. The DON stated authorization to open the E-kit was still pending. The DON stated she did not know that Norco had not been administered as ordered for Patient 1. A concurrent interview and review of Patient 1's Nurses Progress Note with the DON dated 12/3/21 at 12:54 PM, the DON stated the facility's E-kit could not be opened by the licensed nurses to obtain Norco for Patient 1, because Physician 1 had not called the pharmacy to authorize the use of Norco. The Progress Note indicated the DON attempted to call Physician 1 on 12/3/21 at 9 AM and 10:30 AM but was unsuccessful. The Progress Note indicated that on 12/3/21 at 11:30 AM, (approximately 14 to 15 hours after Patient 1 was admitted to the facility), LVN 1 was able to open the E-kit and administer Norco 10-325 mg to Patient 1 for a 9 out of 10 pain level. During a concurrent interview with Registered Nurse (RN) 1 and review of Patient 1's Nurses Progress Notes, on 12/7/21 at 11:40 AM, RN 1 stated Patient 1 was admitted to the facility late in the night, on 12/2/21. RN 1 stated she admitted Patient 1. RN 1 stated that Patient 1's physician orders on admission was verified by Physician 1 on 12/2/21, and RN 1 faxed the admission orders to the facility pharmacy. RN 1 stated medications usually arrive within four hours from the facility pharmacy. RN 1 stated she confirmed the physician's order for the administration of Norco for Patient 1 with Physician 1, but Physician 1 still needed to authorize Norco with the facility pharmacy because it was a controlled medication. RN 1 stated the authorization should be done between the facility pharmacy and Physician 1, when a medication was not authorized or verified (a form, supplied by the pharmacy completed by facility staff, and kept in the patients' chart) by a physician. RN 1 stated she could not find documented evidence of the completed facility pharmacy authorization form in Patient 1's medical records. RN 1 stated when a patient is in pain, and medications was not available in the facility, a follow up call to the physician should be conducted more than once to obtain authorization to open the facility E-kit to treat patients. During an interview on 12/27/21 at 9:57 AM, the facility's Medical Director (MD 1) stated it was the facility's practice that during new admission, the patient's admission orders were verified by licensed nurses with the physicians. MD 1 stated the facility pharmacy would reach out to the physician to authorize the orders. MD 1 stated that facility staff was always able to reach MD 1, whenever needed. MD 1 stated prior to opening the facility E-kit, the pharmacy must approve the authorization from the ordering physician. MD 1 stated pain was not a life-threatening situation but a sensitive situation. MD 1 stated that Physician 1 must always call the facility back. MD 1 stated it was the role of the licensed nurses to reach out to the physician to notify of any patient situations. During an interview on 1/3/22 at 9:14 AM, the DON stated when patients are in pain, the licensed nurses should conduct more than one follow-up call to notify the physician, and it was the responsibility of the licensed nurse to call again, when physicians calls were not returned right away. The DON stated when patients experience pain, a patient might hallucinate (experience a seemingly real perception of something not actually present), and if pain medications were not effective or not available, non-pharmacological (type of health intervention which is not primarily based on medication) interventions should be implemented such as offerings of warm liquids, watching television, and/or repositioning. The DON stated when pain was unrelieved, it can further decline the health status of patients. The DON stated unaddressed and unrelieved pain leads to refusal of care and treatment. During a telephone interview on 3/3/22 at 9:18 AM, LVN 2 (12/2/21 night shift nurse [11 PM to 7 AM]) stated Patient 1 had been in pain but was awaiting Patient 1's medications from pharmacy. LVN 2 stated he had administered Tylenol to Patient 1. LVN 2