Health inspection·October 9, 2024

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 § 72311. Nursing Services – 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 plan shall be based in this plan. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (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. § 72313. Nursing Services – General. (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed. § 72355. Pharmaceutical Services – Requirements. (a) Pharmaceutical service shall include, but is not limited to, the following: (1) Obtaining necessary drugs including the availability of 24-hour prescription service on a prompt and timely basis as follows: (B) Anti-infectives and drugs used to treat severe pain, nausea, agitation, diarrhea or other severe discomfort shall be available and administered within four hours of the time ordered. § 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. An unannounced visit was conducted by California Department of Public Health on 8/23/2024 at 4 PM to investigate a complaint regarding pain medication not given. The facility failed to provide effective pain management that met professional standards of practice for Patient as evidenced by: 1. Failing to do follow up call to Patient 1’s attending doctor (MD 1) after the first call on 8/21/24 at 4:34 PM until 8/22/2024 at 7 AM to get Patient 1’s order for Norco (a controlled medication [a drug or other substance that is tightly controlled by the government because it may be abused or cause addiction] used to reduce moderate to severe pain) authorized. 2. Failing to give Patient 1 appropriate pain medication (Norco) for a pain level of 8/10 (very strong pain/ severe pain; based on a 0 to 10 numerical scale where 0 means no pain and 10 is the worst pain ever felt) when Patient 1 requested for Norco on 8/22/24 at 1:30 AM. 3. Failing to provide documented evidence that Patient 1’s pain level was reassessed for effectiveness one (1) hour after giving the patient Naproxen (a medication used to treat pain) on 8/22/24 at 3 AM. 4. Failing to provide documented evidence that Patient 1’s pain level was assessed before giving as needed (PRN) Tylenol (a medication used to treat pain and/ or fever) on 8/22/24 at 3:16 AM. This deficient practice resulted in Patient 1 experiencing excruciating pain (severe pain that is disabling and significantly limits the ability to perform normal activities and interferes with sleep) on 8/22/24 at 1:30 AM until 3:16 AM. A review of Patient 1’s Admission Record indicated the patient is a 61- year- old- male patient who was admitted to the facility on 4/20/22 with diagnoses that included paraplegia (paralysis of the legs and lower body), type 2 Diabetes (a disease in which your body does not produce enough insulin needed to control sugar levels in the blood), morbid obesity (when a person’s weight is more than 80 to 100 pounds above their ideal body weight) and chronic obstructive pulmonary disease (COPD; a chronic inflammatory lung disease that causes obstructed airflow from the lungs).    During a review of Patient 1’s Care Plan titled Patient 1 has chronic pain related to history of neck and back surgeries and type 2 Diabetes revised on 1/22/24, indicated the following interventions: 1. Administer medications as ordered and monitor for their effectiveness and side effects. 2. Anticipate need for pain relief and respond immediately to any complaint of pain. 3. Assess and document the patient’s pain. 4. Evaluate the effectiveness of pain interventions. 5. Notify physician if interventions are unsuccessful. A review of Patient 1’s Order Summary Report dated 4/3/24 indicated, Patient 1 had an order for Naproxen 500 mg by mouth every 12 hours as needed for moderate pain (pain level of 4 to 6/10). A review of Patient 1’s Order Summary Report dated 4/7/24 indicated, Patient 1 had an order for Tylenol 325 mg by mouth every four hours as needed for moderate pain (pain level of 4 to 6/10). A review of Patient 1’s Minimum Data Set (MDS; a care assessment and screening tool) dated 7/4/24, indicated the patient was assessed to have intact cognition (capable of remembering, learning new things, concentrating, or making decisions that affect everyday life) and was dependent (helper does all effort) when showering, lower body dressing, putting on footwear. The MDS also indicated Patient 1 was assessed to require partial assistance (helper does half the effort) for oral hygiene, toileting, upper body dressing and personal hygiene. A review of Patient 1’s Medication Administration Record (MAR) for the month of August 2024, the MAR indicated Patient 1 was ordered Norco 10/325 mg by mouth every six hours as needed for severe pain (pain level of 7 to 10/10) on 3/29/24. A review of Patient 1’s Progress Notes dated 8/21/24 timed at 4:13 PM, indicated Registered Nurse (RN) supervisor changed Patient 1’s primary doctor and doctor’s name on Norco order and faxed it to pharmacy, notified MD 1 of medication authorization form to be signed.” A review of Patient 1’s Progress Notes dated 8/22/24 timed at 2:35 AM, indicated “Patient 1 was agitated and wanted his Norco to be given, supply at facility was depleted”. The progress notes also indicated; Patient 1 recently changed primary doctor as such order for controlled medication (Norco) was pending authorization. A review of Patient 1's Progress Notes dated 8/22/24 timed at 3 AM, indicated Patient 1 requested Norco, awaiting authorization from doctor’s (MD 1) office so Patient 1was given Naproxen oral tablet 500 mg for pain (did not indicate Patient 1’s pain level). A review of Patient 1's Progress Notes dated 8/22/24 timed at 3:16 AM, indicated Patient 1 was given two (2) tablets of Tylenol tablet 325 mg. The notes did not indicate Patient 1’s pain level. A review of Patient 1’s Medication Administration Record (MAR) for the month of August 2024, the MAR indicated the following: a. Patient 1 received Norco 10/325 mg by mouth on 8/21/24 at 7:41 PM and on 8/22/24 at 8:58 AM (13 hours and 17 minutes apart). The notes indicated the follow up code for both dates were effective. b. Patient 1 was given Naproxen oral tablet 500 mg at 3 AM and the follow up code indicated “unknown” for the effectiveness. c. Patient 1 was given 2 tablets of Tylenol 325 mg at 3:16 AM (16 minutes apart from Naproxen tablet) and the follow up code indicated effective. A review of Patient 1's Progress Notes dated 8/22/24 at 07:36 am, indicated placed Norco10mg order under the care of new attending primary doctor, MD 2, received the signed authorization form and faxed it to the pharmacy. The notes also indicated, at 08:58 AM assigned licensed nurse administered medication to Patient 1 for the patient’s rated pain level of 10/10. A review of Patient 1's Progress Notes dated 8/22/24 at 9:30 AM (8 hours from 1:30 AM when Patient 1 complained of pain level of 8/10), indicated Patient 1's Norco effectively relieved Patient 1's pain. The progress notes did not indicate Patient 1’s pain level at the time of the evaluation.   During an interview on 8/23/24 at 4:26 PM with Patient 1, Patient 1 stated, at 1:30 AM on 8/22/24, Patient 1 asked for his Norco 10 mg for excruciating pain with pain level of 8/10 and did not get it until approximately around 9 AM (approximately 7.5 hours). Patient 1 stated “I was in excruciating pain during that time. The Licensed Vocational Nurse (LVN) 1 told me he did not have the combination to the safe to get the medication. He gave me a Naproxen at 3 AM hours and a Tylenol after.” During an interview on 8/23/24 at 4:47 PM with LVN 1, LVN 1 stated, he could not give Patient 1’s Norco on 8/22/24 around 1:30 AM because Patient 1 had recently changed his primary doctor to MD 1 and MD 1 had to sign an authorization form for the Norco on 8/21/24 at 4:13 PM. LVN 1 stated without the signed authorization form he was unable to obtain the passcode required to get the Norco from the Stat Safe (medication storage safe that needed a code to be able to access). LVN 1 stated Patient 1 reported a pain level of 8 to 9/10 and that he called the Director of Nursing (DON) on 8/22/24 after 1:30 AM to report that he could not get an access code from the pharmacy to get the medication and he could not get in contact with the DON. During a concurrent interview and record review on 8/24/24 at 7:49 AM with LVN 1, Patient 1’s MAR dated 8/1/24 to 8/31/24 was reviewed. The MAR indicated Patient 1 received Naproxen 500 mg by mouth on 8/22/24 at 3 AM for a reported pain level of 8/10. LVN 1 stated, LVN 1 was not able to contact the DON during LVN 1’s shift (night shift; 11 PM to 7 AM) on 8/22/24. LVN 1 also stated LVN 1 did not try to call MD 1 to try to get Patient 1’s Norco order authorized and signed. LVN 1 stated, LVN 1 should have called MD 1 and LVN 1 gave Patient 1 Naproxen while Norco was not available. LVN 1 also stated the Naproxen medication was not appropriate for the reported pain level of 8/10 since the order was to give it for pain level of 4 to 6/10. During a concurrent interview and record review on 8/24/24 at 10 AM with LVN 2, Patient 1’s Progress Notes dated 8/21/24 to 8/22/24 and MAR dated 8/1/24 to 8/31/24 were reviewed. The Progress Notes and MAR did not indicate documentation of pain level of Patient 1 when Tylenol 325 was given on 8/22/24 at 3:16 AM. LVN 2 stated, there was no documentation of what was Patient 1’s pain level when Tylenol 325 mg was given on 8/22/24 at 3:16 AM. LVN 2 stated, Patient 1 should have been evaluated or reassessed after at least 1 hour after the medication was given to check effectivity before going to the next level of pain management if necessary/ pain was not resolved. During a concurrent interview and record review on 8/24/24 at 11:30 AM with the DON, Patient 1’s Progress Notes dated 8/21/24 to 8/22/24 were reviewed. The Progress Notes indicated: 1. On 8/21/24 at 3:54 PM, Patient 1’s attending doctor was changed to MD 1. 2. On 8/21/24 at 4:13 PM MD 1 was notified to get authorization form (for Norco) signed. The DON stated, the authorization form was for the order for Norco and when DON returned to work on 8/22/24, the DON found out that MD 1 did not return the call to sign the Norco authorization form. MD 1 should have been called every hour since Patient 1 requests this medication routinely, but MD 1 was not called. During a concurrent interview and record review on 8/24/24 at 11:54 AM with the DON, the facility’s policy and procedure (P&P) titled, Pain Management dated 6/1/17 was reviewed. The P&P indicated, Purpose: to ensure accurate assessment and management of the patient’s pain. The P&P also indicated, if a patient’s pain has not been relieved with current medication, the Licensed Nurse will notify the attending physician for a review of medications and nursing staff will implement timely interventions to reduce the severity of pain. The DON stated the licensed nurse should have called MD 1 to get Patient 1’s Norco authorized and the consequences of not notifying the MD about medication renewal is that Patient 1 experienced unrelieved pain for an extended period from 8/22/24 at 1:30 AM until 9 AM. The DON stated this is unacceptable. The DON also stated, the pain level needs to be reassessed after one hour if it is an oral medication and the doctor should be notified if the medication is not effective. The facility failed to provide effective pain management that met professional standards of practice for Patient as evidenced by: 1. Failing to do follow up call to Patient 1’s MD 1 after the first call on 8/21/24 at 4:34 PM until 8/22/2024 at 7 AM to get Patient 1’s order for Norco authorized. 2. Failing to give Patient 1 appropriate pain medication (Norco) for a pain level of 8/10 when Patient 1 requested for Norco on 8/22/24 at 1:30 AM. 3. Failing to provide documented evidence that Patient 1’s pain level was reassessed for effectiveness 1 hour after giving the patient Naproxen on 8/22/24 at 3 AM. 4. Failing to provide documented evidence that Patient 1’s pain level was assessed before giving PRN Tylenol on 8/22/24 at 3:16 AM. This deficient practice resulted in Patient 1 experiencing excruciating pain (severe pain that is disabling and significantly limits the ability to perform normal activities and interferes with sleep) on 8/22/24 at 1:30 AM until 3:16 AM. The above violation had a direct or immediate relationship to the health, safety, or security of Patient 1.