cms_UT: 99
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 99 | PIONEER CARE CENTER | 465020 | 815 SOUTH 200 WEST | BRIGHAM CITY | UT | 84302 | 2019-10-28 | 697 | D | 1 | 0 | KWP211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, it was determined, for 1 of 7 sampled residents, the facility did not ensure that pain management was provided for residents who required such services, consistent with professional standards of practice and the residents' goals and preferences. Specifically, one resident did not receive consistent and ongoing pain monitoring and prescribed pain medication while on respite care. Resident identifier: 1. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/28/19, resident 1 was observed in his room. Resident 1 stated that he did not receive all the medications he needed. Resident 1 stated that his pain was usually around 4 or 5 when he wasn't moving, but when he got himself out of bed, the pain was 8 or 9 out of 10. Resident 1 stated that his right shoulder was bone on bone so when he moved, he was close to screaming because of pain. Resident 1 stated that he had chronic back pain, and severe pain in his left thigh muscle. Resident 1 stated that the nurses haven't asked me about my pain. Resident 1 stated that he was taking narcotic pain medication twice a day at home, when he needed it. Resident 1 stated that the more he moved, the more pain he experienced. Resident 1 stated that he had been in severe pain dozens of times a day. Resident 1 stated that he could not call for help every time he went to the restroom because it was at least 4 to 5 times a day and he could not wait for staff. Resident 1 stated that he was in real bad pain when they talked to me a few days ago. On 10/28/19 a record review was conducted for resident 1's electronic medical record. Review of resident 1's physician orders [REDACTED]. This order was started on 10/26/19 at 11:00 AM. Review of resident 1's pain scores revealed the following: a. On 10/26/19, no pain scores were recorded for resident 1. b. On 10/27/19 at 12:49 AM, a pain score was recorded at 0/10. c. On 10/28/2019 at 1:05 PM, a pain score was recorded at 5/10. d. On 10/28/19 at 10/28/2019 1:32 PM, a pain score was recorded at 3/10. The Treatment and Monitoring for resident 1 was that nurses were to 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. One entry for the morning of 10/27/19 recorded no pain, but non-pharmacological pain interventions were utilized, which included repositioning, reassurance/emotional support, rest period/quiet environment, and laughter/socialization. Review of the Medication Administration Record [REDACTED]. Resident 1's baseline care plan revealed that pain was not addressed. The two focuses included in resident 1's care plan were: a. activities of daily living (ADL) deficit, and b. limited physical mobility. The electronic record revealed that the required tasks for the Certified Nursing Assistants (CNAs) to complete for resident 1 included documentation that assistance required was for resident 1's Activities of Daily Living (ADLs), ranging from supervision to extensive assistance. A nursing note on 10/26/19 at 5:27 PM, revealed Resident did not bring prescription of [MEDICATION NAME] with him. Hospice notified, but they were unwilling to provide more because he is 'on hold with them'. On call provider (name withheld) not answering phone. (Note: The on-call physician was not contacted after the Hospice company stated that resident 1 was not currently receiving hospice services.) Resident 1 was followed by a hospice company, who provided documentation for resident 1's admission. The hospice company included the order for [MEDICATION NAME] 325-[MEDICATION NAME] 10 mg tablet, 1 tablet by mouth every four hours, if needed, on resident 1's orders, and included information that it was not being provided by the hospice comapny. The respite stay was expected to be for 9 days while family was out of town. The hospice company progress notes revealed that resident 1 had a prescription for [MEDICATION NAME] 325-[MEDICATION NAME] 5 mg. The prescription stated: a. On 7/8/19, the order was for 1-2 tablets every 6 hours as needed for pain. b. On 9/24/19, the order one tablet every 6 hours. (Note: This prescription was increased to twice as much [MEDICATION NAME] (10 mg versus 5 mg previously) and the frequency of medication administration decreased from 6 hours to four hours.) c. On 10/11/19, the order was for 325-10, one tablet every 4 hours. The order was completed on 10/20/19, with additional doses that were not provided by the hospice company. On 8/6/18, a hospice company progress note revealed that resident 1 had pain with active ROM (range of motion) of left thigh. Pain is also chronic for resident 1's lower back. On 10/28/19 at 12:20 PM, an interview was conducted with CNA 1. CNA 1 stated that she did not assist resident 1 since he was admitted . CNA 1 stated that she was assigned to the hall, but resident 1 did not require assistance. On 10/28/19 at 12:22 PM, an interview was conducted with CNA 2. CNA 2 stated that she brought resident 1 his breakfast, brought resident 1 a drink at breakfast, and refilled his water, but did not assist resident 1 to the restroom or assist him with any other cares On 10/28/19 at 12:11 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that staff should have attempted more than once to obtain pain medication for resident 1. On 10/28/19 at 12:25 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that all residents' pain was assessed upon admission. RN 1 stated that she was aware that resident 1 had requested pain medications on 10/26/19, but resident 1's narcotic pain medication was not available. RN 1 stated that resident 1 had reported pain at 7, which was not recorded in the medical record. RN 1 stated that resident 1 had reported pain. RN 1 stated that she did not know if resident 1's pain was related to [MEDICAL CONDITION]. RN 1 stated that resident 1 had a list of current orders with pain medication but because staff didn't have a signed prescription, they could not get resident 1's pain medication. On 10/28/19 at 12:18 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that resident 1 had complained of chronic back pain on the weekend. LPN 1 stated that resident 1 did not ask for help most of the time, so he was not assessed when he transferred or ambulated. On 10/28/19 at 12:27 PM, an interview was conducted with the Nurse Practitioner (NP). The NP stated that she was informed that resident 1 required pain medications approximately one hour earlier. The NP stated that the office had been contacted over the weekend, on 10/26/19, due to resident 1's pain. The NP reported that facility staff did not report significant pain for resident 1. The NP stated that pain medication was not provided, but a prescription could have been faxed for narcotic medication if a report of serious pain had been conveyed by staff. The NP stated that weekend on-call providers did not visit residents at facilities. | 2020-09-01 |