Health inspection·May 24, 2024

F697 Pain Management §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 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. § 72315. Nursing Service-Patient Care (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. (d) Each patient shall be provided care which shows evidence of good personal hygiene, including care of the skin. (e) Each patient shall be encouraged and/or assisted to achieve and maintain the highest level of self-care and independence. Every effort shall be made to keep patients active, and out of bed for reasonable periods of time, except when contraindicated by orders of a licensed health care practitioner acting within the scope of his or her professional licensure. (f) Each patient shall be given care to prevent formation and progression of decubiti, Such care shall include: (1) Changing position of bedfast and chairfast patients with preventive skin care in accordance with the needs of the patient. (5) Providing care to maintain clean, dry skin free from feces and urine. (6) Changing of linens and other items in contact with the patient, as necessary, to maintain a clean, dry skin free from feces and urine. (7) The facility shall notify the physician, when a decubitus ulcer first occurs, as well as when treatment is not effective, and shall document such notification as required in Section 72311(b). (i) Measures shall be implemented to prevent and reduce incontinence for each patient and shall include: (2) An individualized plan, in addition to the patient care plan, for each patient in a bowel and/or bladder management program. (3) A weekly written evaluation in the progress notes. On 4/9/24 at 8:30 AM the Department of Public Health conducted an annual recertification survey to § 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. On 4/9/24 at 8:30 AM, an unannounced visit was made, to conduct the facility’s Annual Health Recertification Survey. During the survey, the California Department of Public Health (CDPH) conducted an investigation regarding the quality of care and quality of life at the facility and of Patient 1. As a result of the investigation, CDPH determined that the facility failed to ensure: 1. Patient 1 was assessed, monitored, and evaluated for pain and skin breakdown related to MASD (Moisture-associated skin damage caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, mucus, saliva, and their contents. MASD is characterized by inflammation of the skin, occurring with or without erosion [gradual destruction of tissue] or skin infection) and fungal infection (irritation or swelling of the skin cause by overgrowth of fungus) in accordance with the facility's policy and procedure and patient’s plan of care. 2. 2. Patient 1 was assessed and provided care, interventions for pain management to relieve severe pain related to MASD.3. 3. A plan of care was developed to address Patient 1’s complaint of pain related to MASD during cleaning and changing of incontinent brief. 4. Patient 1's plan of care was implemented to assess and document status of wound perimeter; wound bed and healing progress and report improvements and declines to medical doctor and patient. 5. The Treatment Nurse (TN) assessed, monitored, and evaluated Patient 1' s skin weekly for as needed for and document and describe wound measurements, color, type of tissue in wound bed, drainage, odor, and presence of pain as indicated in the facility’s policy and procedure. 6. Patient 1’s name was not listed in the "Assessment History" for "Skin Only Evaluation" in the facility's computerized charting system to prompt the TN to assess the patient's skin condition. 7. The TN informed the physician and documented on a "Change of Condition" report (COC) when Patient 1' s wound worsened in size, new rashes and fungal infection (characterized by itchy skin, redness and rashes due to fungus) was noted. 8. The physician order was implemented for Patient 1 to leave perineal area open to air, at bedtime until resolved due to severe MASD. 9. The Primary Physician (PP1) physically assessed and evaluated Patient 1' s skin to ensure the skin treatment ordered was adequate and effective. This failure resulted in Patient 1' s wound to delay healing or worsened by having unrelieved severe pain and verbalized feeling "sad" that the facility allowed her to suffer from pain, which prevented her from moving around and attending activities that can potentially cause a decline in the patient’s physical health and quality of life. A review of Patient 1’s "Admission Record" indicated Patient 1 was admitted to the facility on 2/8/24 with diagnoses that included Type 2 Diabetes Mellitus (a disease when blood sugar is too high) with hyperglycemia (high blood sugar), urinary tract infection (presence of disease causing organism in the urinary tract [the organs that make and remove urine from the body]) sepsis (blood poisoning by bacteria), immunodeficiency (the decreased ability of the body to fight infections and other diseases), adult failure to thrive (condition when an older adult has a loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal), and pressure ulcer (skin damage caused by constant unrelieved pressure or friction on one area for a long time). A review of Patient 1's "History and Physical (H&P)," dated 2/8/24, indicated Patient 1 has the capacity to understand and make decisions. A review of Patient 1's Minimum Data Set (MDS- a comprehensive assessment and screening tool), dated 2/11/24, the MDS indicated, Patient 1 was cognitively intact (able to think, remember and reason) and was dependent (helper does all of the effort. Patient does none of the effort to complete the activity. Or the assistance of two or more helpers is required for the patient to complete the activity) in shower/bathe self, needed substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) in toilet hygiene (the ability to maintain perineal hygiene) and personal hygiene. A review of Patient 1's "Care plan," dated 2/8/24, indicated Patient 1 had a rash of the perineal (body area between the anus and vaginal area) extending to perianal (body area near the anus) redness related to severe MASD. The plan of care indicated a goal to prevent no complications from rash. To prevent signs and symptoms of infection of the rash the interventions included to monitor for skin rashes for increased spread or signs of infection. A review of Patient 1’s "Care plan," dated 2/11/24, indicated Patient 1' s pain experience related to her perineal and perianal skin breakdown indicated no specific intervention to manage patient’s pain in the perineal and perianal area. A review of Patient 1's "Care plan," dated 2/27/24, indicated Patient 1 was at risk for skin break down related to impaired mobility, cognitive impairment, and diabetes mellitus and the goal was that the patient risk for skin breakdown/pressure ulcer will be minimized daily. The interventions included to administer treatment/medication as ordered and monitor for effectiveness and delayed healing. A review of Patient 1's "Care plan," dated 3/1/24, indicated Patient 1 had a potential to develop pressure ulcer, and the interventions included to assess/record/monitor wound healing on a weekly basis and as needed; assess and document status of wound perimeter; wound bed and healing progress; report improvements and declines to medical doctor and resident/patient representative. The interventions also included to follow facility polices/protocols for the prevention/treatment of skin breakdown and inform the resident/family/care givers of any new area of skin breakdown. A review of Patient 1's "Order Summary Report," (a physician's order summary) for April 2024, indicated on 4/1/24 Patient 1' s physician ordered the patient to receive perineal care to cleanse with soap and water, pat dry, apply Zinc Oxide (skin barrier medication for diaper rash) leave open to air, at bedtime until resolved due to severe MASD, and an order for an external (outside) cream Nystatin-Triamcinolone (a medicine used to treat certain fungus infections) to apply to perineal are topically every day shift for MASD until resolved. During an interview on 4/9/24 at 2:29 PM, Patient 1 stated she was admitted to the facility two months ago with skin redness on her buttock. Patient 1 stated she feels the skin redness to the buttocks, "got worst" and now caused the worst pain she ever experienced. Patient 1 stated, she believed wearing diaper for a long period of time contributed to her worsened wound condition that is causing her severe pain. During an observation in Patient 1's room on 4/10/24 at 9:45 AM, Certified Nurse Assistant (CNA) 6 was assisting Patient 1 to change brief. While being assisted by CNA 6, Patient 1 was observed "moaning saying "Ahhh..ahhh". Patient 1' s perineal and perianal skin area was observed with left buttock (close to the perianal area) maroon colored skin discoloration approximately measure 5 cm x 7 cm with multiple open lesions (area of abnormal or damaged tissue caused by injury, infection, or disease), scattered redness and dry skin peeling off and rashes covering the buttock area extending to the back of bilateral (both sides) upper thigh. CNA 6 was observed continuing to clean Patient 1 while the patient was moaning and saying "Ahhhh" and without stopping or asking why Patient 1 was moaning while telling Patient 1 "It's ok, it's ok." During an interview on 4/10/24 at 9:59 AM, Patient 1 stated, she had to always keep her brief on because she was incontinent (no control) of bowel movement and urination and the staffs does not come sooner to change her and she does not want to lay on a wet bed constantly. Patient 1 stated, she was moaning because she had severe pain on her wound in the perineal and perianal area. Patient 1stated, she always had pain from her wound when she is being cleaned by the CNAs. Patient 1 described her pain level as around eight (8) to ten (10) on a pain scale (0 for no pain and 10 for severe pain) and the worst pain she ever experienced. Patient 1 stated, she used to ask to pain medication in the past and they would sometimes bring Tylenol (a pain relieved medication) to her, but she was not given any pain medications in the last few weeks. During an interview on 4/10/24 at 10:30 AM with CNA 6, CNA 6 stated, Patient 1 always had pain while being cleaned and brief change. CNA 6 was asked if she reported to the charge nurse that Patient 1 had pain every time she was being changed and cleaned, CNA 6 replied "No, the charge nurse should already be aware of it." A review of the physician order, for the month of April 2024, indicated starting 2/29/24, to monitor Patient 1 for pain very shift. A review of the physician's order for April 2024 indicated, no pain medication was ordered for Patient 1. A review of Patient 1’s Progress Notes titled "N (Nursing) Adv (advance) Skilled Evaluation," dated 4/9/24 to 4/11/24 indicated the patient had no pain. However, on 4/9/24 to 4/11/24 was observed by the surveyor and reported by Patient 1 to the surveyor and CNA 6 that she had severe pain on the perineal and perianal area. A review of Patient 1’s Medication Administration Record (MAR) for April 2024 indicated no record that patient receive pain medication prior to wound treatment and at any time from 4/1/24 to 4/11/24. The MAR did not have a section in the record to indicate the pain assessment and level of pain of Patient 1. During an interview on 4/11/24 at 10:56 AM with the TN, the TN stated, she was aware that Patient 1was admitted with severe MASD in the private area up to the anal area on 2/8/24. The TN stated Patient 1' s skin was very red when the patient was admitted which improved in March but got worse again in April. The TN stated she does not know why Patient 1' s wound was worsened. TN stated there was no process to ensure the CNAs were monitored how Patient 1with MASD was kept clean and dry. During a concurrent interview and record review on 4/11/24 at 11:05 AM, with the TN, Patient 1’s Skin assessment records and "Assessment History" were reviewed. The TN stated, she documented on 2/8/24 that Patient 1’s wound was "maceration." TN stated, "maceration means swollen, very bad condition but skin was not open." The TN stated, she was supposed to assess, monitor Patient 1' s skin weekly for healing, but she was not able to do so because Patient 1' s name was not included in the list for the patient ' s to be assessed using the skin "Assessment History." TN stated, the report shows the status of the wound and completed patient’s skin assessment for each patient that are on the list. The TN stated, she would do the patient’s skin assessment when the report indicated "incomplete." The TN showed the surveyor the "Assessment History" record and TN stated, Patient 1was not listed in the report. TN stated, "I have so many residents for skin assessment, so I forgot to do it." During an interview on 4/11/24 at 11:15 AM with the TN, the TN stated, the Wound Consult (WC medical personnel specialized in recommending wound management) was not ordered by the physician to assess Patient 1' s wound. The TN stated, "I classified it (Patient 1’s wound) as MASD because it was in the "pee-pee" and "poo-poo" area (referring to the perineal and perianal area). The TN stated, on 4/1/24, she put in an order for Nystatin-Triamcinolone external cream as a treatment for severe MASD after she speaking to the Wound Consultant (WC) about MASD treatment. The TN stated, she then called the primary physician for Patient 1 about the treatment and the doctor ordered the Nystatin-Triamcinolone cream without assessing the wound. The TN stated, the WC did not see Patient 1’s wound on 4/1/24 when the order for patient’s wound was placed on 4/1/24 or at any time. During an interview on 4/11/24 at 1:29 PM with CNA 5, CNA 5 stated, CNA 5 had been taking care of Patient 1 since the patient was admitted to the facility. CNA 5 stated, Patient 1always had pain in her perineal area during brief change and when sitting on