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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 89 | PIONEER CARE CENTER | 465020 | 815 SOUTH 200 WEST | BRIGHAM CITY | UT | 84302 | 2018-06-21 | 697 | G | 0 | 1 | EUNP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined for 2 of 31 sampled residents that the facility did not ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, a hospice resident reported that her pain medication was ineffective and her hourly pain medication was not being administered; and a vulnerable resident was observed to be in pain without any observed relief provided. The deficient practices identified was found to have occurred at a harm level. Resident identifiers 23 and 38. Findings include: 1. Resident 23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/18/18 at 8:16 AM, resident 23 was interviewed. Resident 23 stated her pain was located in the head, neck, and back and was currently a 8/10 (On a numeric pain scale of 0 to 10. With 0 meaning no pain and 10 the worst pain.). Resident 23 stated that [MEDICATION NAME] was recently started for her pain and that the pain was not controlled with medication. On 6/18/18 at 9:00 AM, an observation was made of resident 23 ambulating to the smoking patio for the scheduled smoke time. On 6/18/18, resident 23's electronic medical records were reviewed. Review of the physician orders [REDACTED]. a. [MEDICATION NAME] (Concentrate) Solution 20 MG (milligrams)/ML (milliliter), Give 1 ml (milliliter)by mouth three times a day for pain. The order was initiated on 6/15/2018. b. [MEDICATION NAME] (Concentrate) Solution 20 MG/ML, Give 0.5 ml by mouth every 1 hours as needed for pain, SOB (shortness of breath). The order was initiated on 5/4/2018. c. [MEDICATION NAME] (Concentrate) Solution 20 MG/ML, Give 1 ml by mouth every 1 hours as needed for pain, SOB. The order was initiated on 5/4/2018. d. [MEDICATION NAME] HCl ([MEDICATION NAME]) Tablet 15 MG, Give 1 tablet by mouth every 4 hours as needed for pain. The order was initiated on 5/13/2018. e. [MEDICATION NAME] Tablet 325 MG, Give 2 tablet by mouth every 4 hours as needed for General Discomfort related to PAIN The order initiated was on 12/21/2017. f. [MEDICATION NAME] Tablet, Give 800 mg by mouth every 8 hours as needed for Pain related to PAIN The order was initiated on 12/27/2017. g. [MEDICATION NAME] Patch 72 Hour 75 MCG (microgram) /HR (hour), Apply 1 patch [MEDICATION NAME] every 72 hours for Pain - Moderate related to PAIN The order was initiated on 5/2/2018. h. [MEDICATION NAME] Tablet 10-325 MG ([MEDICATION NAME]-[MEDICATION NAME]) Give 1 tablet by mouth every 6 hours as needed for pain. The order was initiated on 5/4/18 and discontinued on 5/13/18. i. Admit onto Hospice Care with (name of hospice company) for [DIAGNOSES REDACTED]. The order was initiated on 5/1/18. Review of the Medication Administration Record [REDACTED] a. No doses of [MEDICATION NAME] or [MEDICATION NAME] 0.5 ml were administered. b. The [MEDICATION NAME] 1 ml every hour was administered ten times until 6/20/18, and 6 of those administrations had a pre-administration pain score of greater than 4 out of 10. c. On 6/19/18, two doses of [MEDICATION NAME] 1 ml were administered at 1:26 PM and 6:29 PM. The pre-administration pain score at 1:26 PM was documented as a 2 by Licensed Practical Nurse (LPN) 3. The pre-administration pain score at 6:29 PM was documented as a 3 by LPN 3. d. On 6/20/18 at 1:50 PM, the patient reported a pre-[MEDICATION NAME] administration pain score of 10/10, and the documentation indicated that it was ineffective. e. The [MEDICATION NAME] was administered 84 times and 68 of those administrations had a pre-administration pain score of greater than 4 out of 10. Review of the MAR for (MONTH) (YEAR) revealed the following: a. [MEDICATION NAME] was administered 3 times on 5/11/18 with a pre-administration pain score of 6/10, on 5/12/18 with a pre-administration pain score of 6/10, and on 5/15/18 with a pre-administration pain score of 4/10. The medication administration on 5/12/18 was documented as ineffective. b. No doses of [MEDICATION NAME] were administered. c. The [MEDICATION NAME] 1 ml every hour was administered 14 times and 11 of those administrations had a pre-administration pain score of greater than 4 out of 10. On 5/15/18 and 5/24/18, the post pain administration was documented as ineffective. d. [MEDICATION NAME] was administered 71 times and 62 of those administrations had a pre-administration pain score of greater than 4 out of 10. On 5/2/18 at 8:24 AM, 5/26/18 at 2:15 PM, and 5/29/18 at 6:44 PM the post pain administration was documented as ineffective. e. [MEDICATION NAME] was administered 28 times and 22 of those administrations had a pre-administration pain score of greater than 4 out of 10. On 5/12/18 at 5:32 PM the post pain administration was documented as ineffective. Review of the Pain Level Summary for (MONTH) (YEAR) and (MONTH) (YEAR) revealed that resident 23 had 231 episodes of pain with a pain score of greater than 4 out of 10. All values were scored with a numeric pain scale. The summary documented the episodes with a warning of High of 4 exceeded. Review of the Care Plan revealed resident 23 has potential for pain. She has recent back pain related to [MEDICAL CONDITION]. Heat/cold effective at times, pain medication effective at times. Scans and pain medications adjusted to meet needs Interventions listed on the care plan include the following: a. Assist with heat/cold packs to lower back pain. Intervention was initiated on 11/30/17. b. Monitor pain q (every) shift, notify MD (Medical Doctor) if interventions are ineffective. Intervention was initiated on 11/30/17. c. Pain medications as ordered per MD. Intervention was initiated on 11/30/17. d. Watch for nonverbal signs or symptoms of pain. Intervention was initiated on 11/30/17. e. See Hospice Care Plan to coordinate care. Intervention was initiated on 5/9/18. Review of the hospice nursing notes revealed the following: a. On 6/7/18, the note stated, She is anxious, worrying about when her next dose of pain meds (medication) due. Resident 23 reported an acceptable pain level of 4 out of 10. b. On 6/5/18, the note stated, Pt. (patient) reports feeling pain not improved at all. Review of the nursing progress note on 6/19/18 stated, .observed using a wheelchair today per her request. (resident 23) continues to experience a decline r/t (related to) her [MEDICAL CONDITION]. Review of the nursing pain evaluation on 4/30/18 revealed that resident 23 reported left flank pain with a numeric pain score of 7 out of 10. The evaluation indicated that resident 23 reported that medications and heat packs makes the pain better. Resident 23 reported that the pain negatively impacts sleep and rest, social activities, appetite, physical activity and mobility, and emotions. On 6/19/18 at 1:15 PM, resident 23 was interviewed. The resident stated that she feels like she has injured her back and her pain was now a 10/10. Resident 23 requested pain medications from Licensed Practical Nurse (LPN) 3 and LPN 3 was observed to administer [MEDICATION NAME] and [MEDICATION NAME]. On 6/19/18 at 2:56 PM, resident 23 was re-interviewed. Resident 23 stated that her pain was currently still the same, at a 10 out of 10 in her lower back and it radiated all through. Resident 23 stated the medication did not alleviate the pain. On 6/19/18 at 3:00 PM, LPN 3 was interviewed. LPN 3 stated that resident 23's pain prior to the medication administration was a 4 and she obtained that number by observing facial grimacing. LPN 3 stated that resident 23 would not give a number score. LPN 3 stated that the follow-up pain score was a 2 based on the Wong Baker FACES pain rating scale. According to the Wong Baker scale, a score of 4 was Hurts a little more and a 2 was Hurts a little bit. It should be noted that the scale rates pain by asking the person to point to the face that depicts the pain they are experiencing and was originally developed for children to help them communicate about their pain. On 6/19/18 at 3:09 PM, resident 23 was observed stating to the Medical Records staff that her back went out and that she can not walk now. Resident 23 stated she can only walk to the bathroom. Resident 23 stated, it hurts like a [***] . The Medical Records staff was observed to ask resident 23 if the physician had seen her and resident 23 indicated no by shaking her head. On 6/20/18 at 11:37 AM, resident 23 was interviewed. Resident 23 stated that her back pain was a 10 out of 10 and not improving. Resident 23 stated that she can longer ambulate independently and now uses a walker or wheelchair to get around. The resident stated that she received [MEDICATION NAME] 3 to 4 times a day. Resident 23 requested this surveyor to inform the nursing staff that she would like some pain medication now. An immediate interview was conducted with LPN 2. LPN 2 stated that resident 23 only has a scheduled order for [MEDICATION NAME] 4 times a day. LPN 2 stated that resident 23 did not have a PRN (as needed) hourly order for [MEDICATION NAME] and that resident 23 refused liquid [MEDICATION NAME] because she does not like the taste. On 6/20/18 at 11:40 AM, resident 23 was re-interviewed. Resident 23 stated that she did not know she could have [MEDICATION NAME] every hour and that she did not refuse it. On 6/20/18 at 12:55 PM, LPN 2 was re-interviewed. LPN 2 stated that she administered [MEDICATION NAME] and [MEDICATION NAME] to the resident immediately after she requested it at 11:37 AM. LPN 2 stated that the resident reported her pain was a 8 out of 10 prior to the pain medication administration and a 4 out of 10 after administration. LPN 2 stated that the resident always rated her pain using the numeric pain scale. On 6/20/18 at 1:07 PM, a repeat interview was conducted with resident 23. Resident 23 stated that she received her [MEDICATION NAME] earlier and it did not help. Resident 23 stated her pain was still a 10 out of 10. Resident 23 stated that sometimes she got a heating pad for her back and it kind of helps. Resident 23 stated that optimally an acceptable pain level for her would be a 1. On 6/20/18 at 1:46 PM, LPN 2 was interviewed. LPN 2 stated that resident 23's acceptable pain level was none, or a 3 or less. LPN 2 stated that she was unaware of the PRN [MEDICATION NAME] order until this surveyor notified her. It should be noted that the PRN order for [MEDICATION NAME] was initiated on 5/4/18. On 6/21/18 at 8:00 AM, LPN 3 was interviewed. LPN 3 stated that resident 23 does not always provide a numeric pain score rating. LPN 3 stated that if the resident verbalized it's bad then she scored it as a 4 out of 10, verbalized horrible she scored it as 7 out of 10, and verbalized can't stand it scored it as a 9 out of 10. On 6/21/18 at 11:47 AM, the Director of Nursing (DON) was interviewed. The DON stated that resident 23 reported pain in her neck and that overall the resident has had a general decline and was not necessarily related to pain. The DON stated that she thought resident 23 had a PRN [MEDICATION NAME] order, and that it seems to be effective. The DON stated that the resident complains that the [MEDICATION NAME] tastes bad but they give her chocolate or coffee with it and the resident was able to tolerate it. The DON stated that she has had no reports that the pain medication was ineffective in managing resident 23's pain. The DON was informed of resident 23's decline in mobility, complaints of pain, and reports of ineffective pain control. No additional information was provided. 2. Resident 38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/18/18 at 12:20 PM, resident 38 was observed crying during the lunch meal. The resident was observed to be wheeled to her room by the Medical Records staff. At 12:25 PM, resident 38 was observed to exit her room still visibly agitated and crying. Resident 38 was observed to be moaning and stating hurts repeatedly. At 1:00 PM, resident 38 was wheeled outside for a scheduled smoke break by the Social Service Worker (SSW). Resident 38 was observed to be agitated, crying, and moaning hurts. The Medical Records staff confirmed that the resident was in pain and then wheeled the resident to the nurses station to obtain medication. At 1:10 PM, the resident stated to this surveyor yes when asked if she was in pain. At 1:15 PM, LPN 1 was interviewed. LPN 1 stated that resident 38 suffers from chronic back pain, and that the resident only receives Tylenol for her pain. LPN 1 stated this was due to her history of a drug overdose. LPN 1 stated that the resident was due for her scheduled dose of [MEDICATION NAME] and Tylenol; and was observed to administer these medications. LPN 1 stated that they also alternate between ice and hot packs to try to alleviate resident 38's back pain. Review of physician orders [REDACTED]. a. Tylenol Tablet ([MEDICATION NAME]), Give 500 mg by mouth four times a day related to low back pain. The order was initiated on 7/31/2017. b. Tylenol Tablet ([MEDICATION NAME]), Give 500 mg by mouth every 4 hours as needed for pain. The order was initiated on 7/31/2017. c. Question resident about presence of pain or burning including pressure points. Monitor for pain using 0-10 scale. 0 for no pain, 10 for worst pain possible. If resident is not able to answer, use PAINAD scale, every shift. The order was initiated on 7/5/2017. d. Resident to utilize cold packs PRN for comfort, as needed. The order was initiated on 7/5/2017. e. Resident to utilize hot pack PRN- monitor Q (every) 5-10 for skin redness/discoloration to avoid skin damage, as needed for Pain. The order was initiated on 7/5/2017. Review of the MAR/TAR for (MONTH) (YEAR) revealed that resident 38 received the scheduled Tylenol four times a day. No additional PRN doses of Tylenol were administered. Review of the Pain Level Summary for (MONTH) and (MONTH) (YEAR) revealed that resident 38 had 25 episodes of pain with a pain score of greater than 4 out of 10. The summary documented the episodes with a warning of High of 4 exceeded. Values were scored using the numeric pain scale and the Pain Assessment in Advanced Dementia (PAINAD) Scale. The PAINAD scale scores items a number of 1 or 2. Items scored include breathing, negative vocalization, facial expression, body language, and consolability. Total scores range from 0 to 10, with a higher score indicating more severe pain. Review of care plan revealed resident 38 .has pain related to Chronic back pain. She has a history of opioid abuse. Routine pain medication as ordered. Heat/cold packs for lower back. Intervention listed on the care plan include: a. Administer [MEDICATION NAME] as per orders. Give 1/2 hour before treatments or care. The intervention was initiated on 2/6/18. b. Anticipate (resident's name) need for pain relief and respond immediately to any complain of pain. The intervention was revised on 3/21/18. c. (resident's name) prefers to have pain controlled by: Heat packs. Is able to request heat packs from nurses. The intervention was revised on 3/21/18. Review of the nursing progress notes revealed the following: a. On 6/15/17, the note stated, Pt (patient) with increased anxiousness and leaning forward in her W/c (wheelchair) Ice pack placed on back and 1:1 provided X (times) 30 minutes offering reassurance. b. On 5/20/18, the note stated, .Frequent requests for pills/ice/heat/smokes, often within minutes of receiving the same item requested Struggles to communicate by typing with phone which was her easiest way to communicate until recently. Few words are spoken clearly enough to understand. Staff attempts to anticipate needs and she is able to answer yes no questions. c. On 5/2/18, the note stated, Call in to (doctors name)r/t (related to) increase in falls. Resident also states she has increased pain and is unable to stay upright in her chair. Awaiting response. It should be noted that no documentation could be found for a response from the doctor. d. The post pain intervention follow-up documented 8 episodes of hot pack utilization that were effective and 2 episodes that were ineffective for (MONTH) (YEAR) and (MONTH) (YEAR). Review of the nursing Pain Evaluation on 6/17/18 revealed a numeric pain score of 7 on a scale of 0 to 10, with increasing numbers indicating an increase in pain. The evaluation indicated that resident 38 was able to verbalize pain and has a history of back pain, and that medications and heat make the pain better. The evaluation also documented that the pain negatively impacts sleep and rest, social activities, appetite, physical activity and mobility, and emotions. No documentation could be found in the evaluation section of Describe all methods of alleviating pain and their effectiveness. On 6/19/18 at 10:44 AM, resident 38 was observed. Resident 38 was observed to use her legs to wheel herself out of her room in her wheelchair. Resident 38 stated to the DON hurt, hurt. The DON stated that she was asking for her chapstick. The DON was observed to ask Certified Nursing Assistants (CNAs) to get her chapstick. Resident 38 was observed to wheel herself through the hall crying, Hurt, Hurt, Hurt. There were no staff observed to provide interventions for resident 38 when she stated, Hurt, Hurt. Resident 38 was also observed to lean self forward in wheelchair and place hands flat on the floor. A CNA immediately ran down the hall and resident 38 was taken back to her room. Prior to placing her hands palm down on the floor, resident 38 leaned forward, causing a staff member to grab the back of her shirt. Resident 38 then crossed the hall and was using the handrail to propelled self up the hallway while using her right fist to hit the arm rest and side of the wheelchair. On 6/20/18 at 2:05 PM, CNA 6 was interviewed. CNA 6 stated that the resident would repeatedly state it hurts. CNA 6 stated that when she really wanted something she will text or write it for the staff. CNA 6 stated she applied heat packs to the resident's lower back for pain, and stated it's hard to tell if it helps her pain, but it keeps her calm. CNA 6 stated that if it did not alleviate her pain then resident 38 would keep repeating heat. On 6/20/18 at 2:08 PM, LPN 2 was interviewed with LPN 1 present. LPN 2 stated that resident 38 has chronic pain in her back. LPN 2 stated that the resident was bathing her injured husband and slipped and fell , injuring her back. LPN 2 stated that resident 38 was on narcotic pain medication for her back injury and accidentally overdosed resulting in her [MEDICAL CONDITIONS]. LPN 2 stated that interventions for pain control included hot/ice packs and scheduled Tylenol. LPN 2 stated that nothing took away the pain and she had informed the doctor on multiple occasions but the doctor stated she can only be on Tylenol. LPN 2 stated that it is documented in numerous nursing notes. LPN 2 stated that this has been going on for at least 2 years. LPN 2 stated that she has not seen where any intervention has alleviated resident 38's pain and its really sad. LPN 1 stated its just heartbreaking. It should be noted that the nursing progress notes were reviewed from 7/5/17 to 6/19/18 and only one progress note was identified as having informed the doctor of resident 38's pain. On 6/21/18 at 8:00 AM, LPN 3 was interviewed. LPN 3 stated that she scored resident 38's pain by observing her body movements, and back pain was displayed with side to side movements. LPN 3 stated that resident 38 was sometimes able to provide a numeric pain scale, but mostly she utilized the PAINAD scale if I can't understand her. On 6/21/18 at 8:05 AM, LPN 2 was interviewed. LPN 2 stated that she used the PAINAD scale to score the residents pain because she was nonverbal. On 6/21/18 at 9:26 AM, resident 38's physician was interviewed. The physician stated that it was hard to assess the resident's pain and she's really all over the map with her communication. The physician stated that he believed that resident 38's pain was well controlled. The physician stated that it was difficult to assess the resident's pain with her [MEDICAL CONDITIONS], but that he thought the pain was well managed. The physician stated that resident 38 had not exhibited a lot of problems with pain. The physician stated that resident 38 had no complaints of chronic pain and was in the facility for an opioid overdose. The physician further stated that he did not have any problems with ordering pain medications for resident 38 in a clinical setting, but he did not see a need or indication for more pain management. On 6/21/18 at 9:34 AM, the DON was interviewed. The DON stated that resident 38 suffered from chronic low back pain. The DON stated that the resident had Tylenol ordered to cover the pain and it was effective. The DON further stated that resident 38 can have a heat pack and cold pack for pain. The DON stated that the nursing staff had not reported that her pain was not well controlled. The DON stated that staff assessed for pain by asking the resident, and the resident will state hurt. The DON stated that the resident's behavior would also indicate the need for other things such as smoking, chap stick, ice cream, pills (just states pills). The DON stated that the MAR indicated [REDACTED]. On 6/21/18 at 9:56 AM, resident 38's spouse was interviewed. The spouse stated that resident 38 has chronic pain in head and back, and that the facility gave her Tylenol for pain management. The spouse stated that the medication was not effective to alleviate the pain. The spouse stated that he talked to the facility staff about resident 38's pain, all the time. The spouse further stated that he had a discussion with the resident's physician on 6/18/18 and that the physician did not want to prescribe anything stronger with the resident's past history of abuse and an overdose. On 6/21/18 at 10:30 AM, the SSW was interviewed. The SSW stated that resident 38 exhibited behaviors of repeatedly asking for smokes, pills, heat pack, cold pack, and phone. The SSW stated that the heat and cold pack can indicate lower back pain, but it can be a behavior if she already has a heat pack in place. The SSW stated that the resident's short term memory loss required frequent reminders that the heat pack was in place. The SSW stated that requests for a heat pack were considered a complaint of pain if a pack was not already present. The SSW stated that resident 38 had a high level of anxiety and increased behaviors when her needs were not being met. The SSW stated that when resident 38 had 1:1 care her behaviors were reduced, and that the facility administration helped with her care. The SSW stated that resident 38 can communicate verbally, by typing on a phone, or by a written message. The SSW stated that resident 38 was able to communicate her level of pain and the location of the pain. Additionally, the SSW stated that resident 38 was able to state if the interventions was alleviating her pain if asked specifically about it. The SSW stated that she had wondered if the current interventions of Tylenol and heat packs alleviated her pain. The SSW stated that she believed that resident 38's [MEDICAL CONDITIONS] amplifies her request. The SSW stated that resident 38 had an accidental opioid overdose, and that the opiates were for chronic back pain. On 6/21/18 at 11:47 AM, the DON was re-interviewed. The DON was informed of the multiple observations of resident 38 crying and stating hurts, the interviews with facility staff that stated the pain was not well controlled, and the interview with the physician stating he had not been informed of uncontrolled pain. The DON stated, sound like we are not all on the same page, we have a communication problem. No additional information was provided. | 2020-09-01 |