| 23 |
BENEFIS SENIOR SERVICES |
275012 |
2621 15TH AVE S |
GREAT FALLS |
MT |
59405 |
2019-07-11 |
697 |
G |
0 |
1 |
01HJ11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess and provide pain management interventions during treatment of [REDACTED].#104) of 42 sampled residents, who described his pain as excruciating. Findings include: During an interview on 7/10/19 at 10:34 a.m., resident #104 stated he first noticed the pressure ulcer on his right heel prior to his arrival at the facility. Resident #104 explained the wound itself looked as if it were 90% healed, but .the bad part is the pain. Resident #104 described the pain on his right heel as excruciating, especially when staff performed dressing changes. Resident #104 stated he was unsure if he took pain medications prior to dressing changes on his right heel. During an interview on 7/10/19 at 10:51 a.m., staff member T stated resident #104, is fine, and has not needed or requested pain medications prior to dressing changes on his right heel. During an interview on 7/10/19 at 11:24 a.m., after staff member T was alerted to resident #104's pain, staff member T stated she would perform a dressing change on resident #104's right heel wound in about ten minutes. Staff member T stated, We ended up giving him a pain medication, so we are going to wait for that to kick-in. This was after the surveyor approached the topic of the resident's pain with the staff member. During an observation on 7/10/19 at 11:36 a.m., staff member T performed a dressing change on resident #104's right heel. While staff member T removed the compression stockings, resident #104 groaned in pain, and said Ow! multiple times. Staff member T did not perform a pain assessment, alter treatment, or implement pain relieving measures for resident #104 during the dressing change. During an interview on 7/10/19 at 2:37 p.m., staff member T stated she was not sure of the source of resident #104's pain. Staff member T stated resident #104 takes [MEDICATION NAME] as needed, but only requests it at night, and is not taking any scheduled pain medications. Staff member T stated the dressing change she performed earlier in the morning on 7/10/19 was the first time resident #104 had requested pain medication prior to a dressing change. During an observation on 7/11/19 at 9:02 a.m., staff member G performed wound care on resident #104's right heel. While staff member G removed resident #104's compression wraps and bandage, resident #104 grimaced and tensed his right leg. Staff member G described the wound as a Stage II pressure ulcer, with dimensions of 1.9 cm x 1.2 cm (length x width); she continued to describe the peri-wound as dark pink and beefy red. The wound itself, she said, had slightl red drainage; and yellow, dry, and flaky skin was noted to the top part of the wound, which staff member G peeled off. Resident #104 continued to grimace and tense his right leg throughout wound care. Staff member G did not perform a pain assessment, alter treatment, or implement pain relieving measures for resident #104 during wound care. During an interview on 7/11/19 at 9:18 a.m., staff member G stated she was not sure if resident #104 took pain medications prior to wound care on his right heel. Staff member G said she had not performed a pain assessment with resident #104. Staff member G consulted resident #104's MAR indicated [REDACTED]. Staff member G stated resident #104 takes [MEDICATION NAME], 50 mg tablets, one tablet by mouth once daily, as needed for pain; and [MEDICATION NAME] 1% gel, apply 2-4 grams to affected areas of joint pain up to four times daily. Review of resident #104's care plan, dated 6/11/19, showed under the category, Pain, resident #104 will achieve a consistent level of comfort while maintaining as much function as possible. Interventions under this goal include: -administer pain medications on scheduled and/or as needed basis; -if finding that adequate pain control is not occurring and remains greater than a 5/10 after 30 minutes after pain medication administration, document and notify primary care provider; and, -pre-medicate for pain as needed to optimize participation in therapies, activities and meals. Review of a Training Competency document, dated 2/1/19-2/28/19, showed staff member T met the standard for assessing and reassessing pain; and utilizing appropriate pain management techniques. Review of resident #104's pain assessment notes, between 6/28/19 and 7/11/19, showed five out of 27 pain assessments were completed. Out of those five, one assessment, dated 7/8/19, did not note the location of the resident's pain; one assessment, dated 7/4/19, showed resident #104 was experiencing a burning and restless pain in his right foot; assessments dated 6/26/19, 6/27/19, and 6/30/19 showed resident #104 was experiencing pain in both knees only. |
2020-09-01 |