Terrace View Long Term Care Facility
March 14, 2018 Complaint Survey

Standard Health Citations

FF11 483.25(k):PAIN MANAGEMENT

REGULATION: §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.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 14, 2018
Corrected date: May 10, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during an Abbreviated survey (Complaint #NY 134) completed on 3/14/18, 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 residents' goals and preferences. One (Resident #1) of three residents reviewed for pain had issues with the lack of pain assessments by medical providers and nursing staff for persistent headaches. The finding is: The facility's policy entitled Pain Assessment and Management dated 2/2017 documented it is the responsibility of all care plan team members and all clinical staff to provide resident-centered care and services to address and manage pain. All residents require evaluation for the presence of pain when a symptom of pain is noted. The pain assessment will include identification of pain, physical examination of the reported pain site and evaluation of the type, frequency, intensity, and quality of the pain. The medical team will assess the presence of pain or painful conditions when staff report new onset of pain, increasing severity of pain, or unresolved pain. The medical team will document this assessment in the medical progress notes section of the medical record. The medical team will determine if additional diagnostic testing or evaluation is required to treat the painful condition. The Comprehensive Care Plan team will develop the resident's individualized pain management plan based on the resident's experience of pain, diagnoses, history, and observation and interview with the resident and family. The undated Guidelines for Stratifying Calls by Urgency, identified by the Medical Director and Director of Nursing (DON) as current, revealed 3 classifications: emergency - response within 15 minutes; routine - response within 3 hours; and notification - no response necessary. 1. Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Nursing Admission assessment dated [DATE] documented the resident was alert and oriented to person, place and time without any cognitive impairments. The hospital discharge summary dated 2/23/18 revealed that the resident was admitted on [DATE] for [MEDICAL CONDITION]. The resident was previously hosptalized on [DATE] for worsening anasarca (extreme generalized [MEDICAL CONDITION], swelling caused by excessive fluid accumulation), dyspnea (shortness of breath) on exertion, and had a hemoglobin of 4.9 (normal 12.0 to 15.5). The hematology consultant determined that the resident's [MEDICAL CONDITION] was unlikely caused by hemolysis (abnormal breakdown of red blood cells) and suggested the source was multifactorial including GI (gastrointestinal) and/or related [MEDICAL CONDITION]. Other conditions on the hospital discharge summary included plans for were anasarca, mitral valve disorder, [MEDICAL CONDITION], acute kidney injury, [MEDICAL CONDITION] and heart failure; head ache was not listed in the discharge summary as a resident problem. Admission Physician orders [REDACTED]. The Resident's Plan of Care - General Care Plan dated 2/23/18 documented the resident had pain (no location given) with desired outcomes of a pain level acceptable to the resident who uses the pain scale appropriately. Planned interventions for pain included that all staff perform pain assessments. Review of a Pain Assessment by Licensed Practical Nurse (LPN #3) dated 2/24/18 at 6:59 AM documented the resident had generalized pain and throbbing. The medication effect was documented as positive. The assessment and reassessment did not utilize the numeric scale. Review of the Medication Administration Record (MAR) for 2/24/18 revealed there was no documentation of the administration of Tylenol, and there was no Pain assessment documented for the 3:00 PM to 11:00 PM (3 -11) shift. During an interview on 3/14/18 at 7:10 AM, LPN #3 stated she recalled the resident complained of a headache since admission and her comments regarding her pain were all over the board. On 2/24/18 the LPN worked the day shift (7:00 AM to 3:00 PM (7- 3)) and she recalled that the resident had complained of generalized pain, and she administered Tylenol. When the LPN re-evaluated the resident for effectiveness the resident told her that her head ache was better and she documented the medication had a positive effect. LPN #3 had no explanation for not using the numeric pain scale for the re-evaluation of the resident's pain, had no explanation for the lack of documentation for the administration of the Tylenol on the MAR. Review of a Pain assessment dated [DATE] at 16:00 (4:00 PM) revealed the resident complained of 6/10 (pain scale, 1 to 10 with 10 being the worst) throbbing generalized headache and was given Tylenol 650 mg with a 19:03 (7:03 PM) reassessment result of 0/10. There was no 11:00 PM to 7:00 AM (11-7) Pain Assessment documented on 2/25/18. On 2/26/18 the 3:00 PM to 11:00 PM Pain Assessment at 2300 (11:00 PM) by LPN #2 documented the resident had a headache 4/10 on the right, sharp and throbbing that was alleviated with medication. The reassessment on 2/27/18 at 2:51 AM revealed the medication had minimal effect pain 2/10. There were no additional 11-7, 7-3 and 3-11 pain assessments in the medical record. Review of the MAR dated 2/26/18 revealed there was no documentation of the administration of pain medication/Tylenol. A Nursing SBAR (Situation, Background, Assessment, Recommendation) Communication Form dated 2/27/18 at 2:00 PM, LPN #2 documented the resident had increased anxiety after returning from the emergency room (ER) and had a head ache which was unrelieved with Tylenol. The resident reported the headache began at 12:20 AM, believed the headache was cardiac related and stated she took [MEDICATION NAME] (antianxiety medication) at home. The assessment documented this was a new onset of right frontal lobe head ache and a routine notification message was left for the Nurse Practitioner (NP). During an interview on 3/14/18 at 4:00 PM, LPN #2 stated that she never did receive a call back from the NP on 2/27/18 and when she went back to check on the resident, she had fallen asleep. She gave the information about the resident's headache during change of shift to the Registered Nurse (RN) Unit Manager (RN #1). Review of a Nursing Provider Notification dated 2/27/18 10:19 AM by the RN #1 revealed she provided an in-person notification to the NP that the resident had headaches, nausea and anxiety. The provider gave a new order. There were no pain assessments documented on 2/27/18 for the 7- 3, and 3 -11 shifts. Review of a physician order [REDACTED]. Review of a NP note dated 2/27/18 at 1100 (11:00 AM) revealed the resident's chief complaint was debility and [MEDICAL CONDITION]. The evaluation was for an acute visit for subacute rehabilitation multidisciplinary meeting. The NP documented that since admission to the facility, the resident was sent to the ER for 2 units of PRBC's (packed red blood cells) for a hemoglobin of 6.5. The Review of Systems noted the resident denied headaches, [MEDICAL CONDITION] and [MEDICAL CONDITION]. The Assessment and Plan for Pain documented denies any acute pain or discomfort now, pain medications reviewed, monitor for effectiveness, monitor for over sedation, and follow-up as needed. The note does not identify the location of the resident's pain (head ache), nor the frequency and intensity of the pain (headaches), nor define the medications ordered to treat the pain and anxiety. During an interview on 3/7/18 at 12:01 PM, the NP stated that the resident's goal was to get back home to her children. The resident's responsible party wanted the facility to fix things and her care delivery wasn't moving fast enough. The NP recalled the resident was sent to the ER for blood [MEDICAL CONDITION]. The resident did complain of headaches and stated when she asked the resident what she did in the past, the resident stated she wanted Extra Strength Tylenol. The NP stated at first the resident requested [MEDICATION NAME] because she wasn't sure she was sleeping well enough and she had anxiety. Review of a Nursing Behavior Note dated 2/27/18 10:36 (10:36 AM) by a RN #6 revealed the resident was alert, oriented, calm and cooperative with care and noted with some anxiety. An order was obtained for as needed [MEDICATION NAME] for five days and the first dose was given with some good effect. The resident was not motivated to complete Activities of Daily Living (ADL's) and assist staff with care. Review of the MAR dated 2/28/18 revealed that LPN #6 administered Tylenol 650 mg for complaints of head ache at 6:48 AM. A note on 2/28/18 at 9:13 AM by LPN #7 documented effective. There was no numeric pain scale for the pain re-assessment and no other documented pain assessments on 2/28/18 for the 7- 3 shift. Review of a Nursing Provider Notification Form dated 2/28/18 16:24 (4:24 PM) revealed RN #1 Unit Manager notified the resident's medical doctor (MD) the resident had a nosebleed (epistaxis) that day and had continued menstrual bleeding. Review of a MD #2 Admission History & Physical dated 2/28/18 at 11:48 AM revealed documentation of the resident's severe [MEDICAL CONDITIONS], supratheraputic INR (elevated international normalized ratio, provides information about a person's blood's tendency to clot), epistaxis, cardiorenal syndrome (disorders of the heart and kidneys), diabetes, and history of mitral valve repair and AICD (automated implantable cardioverter defibrillator placement). The physician's review of systems narrative revealed the resident denied headaches, lightheadedness, double vision, lethargy, and shortness of breath. The note included an assessment and plan regarding the resident's [MEDICAL CONDITION]. There was no objective information regarding the resident's headaches or notation that that the resident experienced, and that nursing staff and the NP treated from 2/24/18 through 2/28/18. During an interview on 3/14/18 at 2:13 PM, MD #2 stated that she saw the resident twice, once for a capacity determination (on 2/26/18) and on 2/28/18 for the History and Physical. The resident was alert and oriented and denied head ache and any other symptoms when she saw the resident for the Initial History & Physical. MD #2 stated that she received objective information from staff; however, she did not review the MAR, Pain Assessment Records. During the interview, MD #2 could not recall if she was aware that the resident experienced a headache since admission which required medication, nor did she recall any notification from the NP about the resident's plan of care. Review of a Pain assessment dated [DATE] at 5:30 AM by LPN #3 revealed the resident had a headache 9/10 which was radiating, the resident was moaning, guarding, irritable, rubbing her side, restless and had facial grimacing, and documented the medication had positive effect; there was no numeric scale use for the reassessment. Review of the MAR dated 3/1/18 revealed LPN #3 administered Tylenol 650 mg at 0001 (12:01 AM) and at 4:24 AM. During an interview on 3/14/18 at 7:10 AM, LPN #3 reviewed the 3/1/18 documented pain assessment and stated that the resident exhibited all the documented symptoms and had a massive headache and she couldn't believe they were only administering Tylenol for the headache. LPN #3 could not recall if the resident's head ache was totally relieved and stated the resident's habit on the night shift was to go in and out of sleep. In addition, LPN #3 could not recall if she evaluated the resident's headache symptoms with a numeric scale for each occurrence of administered pain medication. Review of a 3/1/18 Nurse Note by RN #7 revealed the responsible party was concerned about the resident's continued headaches and wanted the resident taken to the ER. The nurse told the responsible party she had seen the resident every day and the resident had not verbalized any complaints of headache and told the responsible party about the new orders (for scheduled Extra Strength Tylenol). Review of a physician order [REDACTED]. The MAR and physician orders [REDACTED]. During an interview on 3/8/18 at 11:55 AM, the NP stated that she thought the resident would get better relief for the headaches with scheduled Tylenol. The NP stated she did not assess the resident on 3/1/18 because there was a snowstorm and she was not in the facility when she gave the verbal order. On 3/1/18 there was no documented pain assessment for the 7- 3 and 3 -11 shifts; however, on 3/2/18 the MAR at 1700 (5:00 PM) indicated the resident received Tylenol 1000 mg. Review of a 3/2/18 pain assessment at 8:17 AM by LPN #3 revealed the resident had generalized pain which was throbbing and guarding and the medication had a positive effect. During an interview on 3/14/18 at 7:10 AM, LPN #3 stated she only worked the night shift and stated she must have completed the chart at 8:17 AM. The resident had generalized pain and a headache on 3/2/18 because she administered the scheduled 1:00 AM Tylenol. She could not recall any other specifics regarding the pain assessments completed. Review of a Pain Assessment on 3/2/18 at 09:15 (9:15 AM) by LPN #4 revealed the resident had a throbbing headache 4/10 with facial grimacing and was given medication. Review of the 3/2/18 10:00 (10:00 AM) re-assessment indicated the resident's head ache was 2/10 after administration of the scheduled pain medication with moderate effect. Review of the MAR dated 3/2/18 revealed the resident received scheduled Tylenol 1000 mg at 0100 (1:00 AM), 0900 (9:00 AM) and 1700 (5:00 PM) and as needed Tylenol 650 mg at 13:55 (1:55 PM) administered by LPN #4 and 2122 (9:22 PM) administered by LPN #1; for a total of 4300 mg. During a telephone interview on 3/9/18 at 6:55 AM, LPN #1 stated she was not aware that the Tylenol she administered on 3/2/18 was over the 4000 milligram limit. At the time of the interview the LPN could not review the closed record because she did not have the security access to view the closed record. Review of a physician order [REDACTED].#1 to decrease the [MEDICATION NAME] to 0.5 mg by mouth every 6 hours as needed for anxiety/migraines. Review of a Nursing Provider Notification Form dated 3/2/18 at 14:00 (2:00 PM) revealed the RN #1Unit Manager notified the NP that the resident continued to complain of a headache, and had new onset of incontinence. The provider gave instructions that it was okay to send the resident to the ER if she was agreeable to go. Review of the 3/2/18 14:00 (2:00 PM) Nursing Resident/Family Education Form revealed the resident was given the option of transfer to the ER for continued complaints of migraine headaches which are not relieved with current interventions. The resident and responsible party was requesting an MRI (magnetic resonance imaging) of the resident's head. The resident stated that she received Tylenol (just administered at 1:55 PM per review of the MAR), was helped back to bed and was feeling better. The resident requested to be checked frequently by staff each shift and the resident was told to inform staff if the headaches reoccur and the resident was to inform staff if she changed her mind and wanted evaluation by the ER. There was no order for a transfer to the ER. During an interview on 3/8/18 at 11:50 AM, RN #1 Unit Manager stated that she talked to the NP and the resident on the afternoon of 3/2/18 about her headaches and gave the resident the option of going to the ER. The resident declined going to the ER and still wanted an MRI she did not recall informing the NP about the outcome. She did inform the next shift about the occurrence and believed that staff were properly monitoring and treating the resident's headaches. RN #1 was not aware the resident exceeded Tylenol limits on 3/2/18; and stated the MD should have been informed about the occurrence. During an interview on 3/8/18 11:55 AM, the NP stated RN #1 Unit Manager informed her that the resident voiced concern about the headaches and wanted an MRI, thus she stated she could go the ER. The NP did not comment on what evaluation the resident required, what was the plan of care or what were the resident's goals, and stated it was the resident's choice. The NP stated she was not in the facility this day, because there was a snowstorm and she did not come into the facility. Review of the MAR dated 3/2/18 revealed RN #5 documented at 17:57 (5:57 PM) the as needed Tylenol administered at 13:55 (1:55 PM) was effective. During an interview on 3/14/18 at 3:55 PM, RN #5 stated that she completed a pain reassessment for the 1:55 PM Tylenol administration at 5:57 PM and documented that the Tylenol was effective. RN #5 stated the facility's policy was to use a numeric pain scale for residents and could not recall if the resident's headache was totally alleviated. Review of physician orders [REDACTED]. Review of a Nursing Post Occurrence assessment dated [DATE] at 04:54 (4:54 AM) by RN # 2 documented at 2:15 AM the resident was transferred from the bed to the bedside commode and when the resident began to lean forward she was lowered to the floor. The resident had no recollection of the event. The resident had a headache 7/10 that was persistent, and no worsening after the incident. The resident was given scheduled Tylenol 1000 mg with minimal effect. At 2:45 AM the on call MD #1 was provided with an initial notification about the incident. Review of a physician order [REDACTED]. Review of a Nursing Behavior Note dated 3/3/18 at 6:34 AM by RN #2 revealed the resident was crying and uncooperative, sad and unmotivated to participate in care, increased anxiety, yelling out at night every time a staff member would leave the room, staff attention given every 15 minutes. The resident stated she did not remember the events of the accident but did identify staff members. The physician was notified and a new order was given for [MEDICATION NAME] 0.25 mg times one. During an interview on 3/7/18 at 10:07 AM, RN #2 stated that two CNA's (Certified Nurse Aides) informed her that while transferring the resident from the bed to the bedside commode the resident was lowered to the floor. The CNA's told her the resident was moved from a lying to sitting position and left for several minutes because she felt light-headed which was normal for her. They moved her to the standing position she felt light headed which was not abnormal for her and they had to lower her to her knees. The resident had a head ache which was persistent throughout the night. After notifying the RN Supervisor, the fire department was called to assist with transfer due to the resident's weight. RN #2 stated the resident was high anxiety all night, she had her responsible party on speaker phone throughout the night, and wanted to be checked every 15 minutes. She notified the physician as a notification status initially based on conferral with the RN Supervisor. RN #2 recalled that she spoke to the NP on the 3-11 shift, she worked a double shift, because the resident was on as needed [MEDICATION NAME] and the resident wanted it changed to [MEDICATION NAME]; however, the NP said no. Later, in the shift she called the on-call MD #1 and stated she informed the physician the resident had a fall. Persistent headache and was anxious with an episode of confusion and got an order to administer a onetime dose of [MEDICATION NAME] immediately. RN #2 stated the resident's speech was clear, and she did not have any vision changes. During an interview on 3/7/18 at approximately, RN #1 Unit Manager stated she completed the 3/3/18 Accident and Incident report which indicated that the resident was lowered to the floor by CNA #1 & CNA #2. During the investigation she spoke to CNA #1 and RN #2. The resident did not hit her head and she believed the post occurrence events were appropriate without care plan violations. During an interview on 3/7/18 at 10:39 AM, the on-call MD #1/Medical Director stated that he received two calls regarding the resident. He stated he spoke to a nurse who told him the resident went down and the fire department had to assist with getting the resident off the floor. She was agitated because she was weaned off [MEDICATION NAME] and he authorized a one-time dose of [MEDICATION NAME]. He did not receive the first call, which was a notification until two days after the event. MD #1 stated the physician group has a 3-tiered call system, 1) notification (no call back, don't beep or come back to him until a couple of days later, 2) routine (call with-in 2-hour), and 3) emergency (call back with-in 10 minutes). During the interview the physician played the first message left by RN #2 who informed him the resident had a persistent headache and was at her baseline mental status; the message did not relay that the resident had no recollection of the event. In addition, MD #1 stated he was never informed that the resident and the responsible party wanted the resident to have a MRI for headaches. The physician stated he reviewed the provider notes and felt that the provider notes should have assessed the resident's headaches when completing their evaluations. Additional interview with MD #1 at 3:06 PM revealed, the resident warranted neurological checks and continued assessment after the fall. During an interview on 3/7/18 at 12:52 PM CNA #1 stated she and CNA #2 completed the transfer when the resident was lowered to the floor. This night the resident was weak. The resident was lightheaded when moving from a lying to a sitting position, which was normal. When the resident was ready, they stood her up. After the event, the resident kept saying she did not recall how it happened. The fire department got the resident back to bed and staff checked on her frequently. During an interview on 3/7/18 at 3:18 PM, CNA #2 stated he and CNA #1 completed the transfer when the resident was lowered to the resident to the floor. CNA #2 stated that the resident was lightheaded when moving from a lying to a sitting position, which was normal. When the resident was ready, they stood her up. This night the resident was weak. After the event, the resident kept saying she did not recall how it happened. The fire department got the resident back to bed and staff checked on her frequently. CNA #2 stated every time he was in the room the resident complained of a headache, blurry eyes, and the nurse on the floor was aware. Review of a Nursing SBAR Communication Form dated 3/3/18 at 9:00 AM revealed the resident had an altered mental status with increased lethargy, and abnormal speech. Vital signs documented were: blood pressure (B/P)120/75 (normal 120/80), pulse 66 (normal 60 -100), respiratory rate of 18 (normal 12 - 20). The NP was called and orders were given to send the resident to the ER. Review of a Nursing SBAR Communication Form dated 3/3/18 at 9:40 AM revealed when entering the resident's room to inform the resident about transfer to the ER, the resident was found unresponsive. The following vital signs were documented: BP 134/86, AR (apical (heart) rate) of 72, and a respiratory rate of 18. Review of a Emergency Department - Attending Note dated 3/3/18 at 10:21 AM revealed the resident's CT (computerized tomography) showed a large right-sided subdural hematoma (serious condition where blood collects between the skull and the surface of the brain) with mass effect and midline shift requiring neurosurgical treatment. During an interview on 3/8/18 at 3:30 PM, the Director of Nursing (DON) stated that she reviewed the resident's medical record when the hospital reported that the resident had a subdural hematoma. The DON stated she interviewed staff and felt that staff followed the fall protocol, including the physician notification. During an interview on 3/14/18 at 4:00 PM, the Assistant Director of Nursing (ADON) stated staff are expected to complete pain assessments and reassessments using the numerical scale for resident who are cognitively able and the faces scale for residents who are unable to relay pain symptoms. 415.12

Plan of Correction: ApprovedApril 11, 2018

F 697 Corrective Action: To assure that pain management is provided to resident who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents?ÇÖ goals and preferences. 1) Resident #1 has been discharged from the facility. Resident #1?ÇÖs chart was reviewed other possible areas of concerns, and none were noted. The nurses on the unit were immediately in serviced on the how to properly complete pain assessments. In addition, the medical providers were immediately notified/ inserviced on proper pain assessment documentation. 2) All residents with pain are at risk for the same deficient practice. A list of all residents who have pain scores greater than 0 and have received PRN pain medications was created on 4/4/18. The residents on the list who received PRN pain medications will be reviewed to assure the PRN pain medication effectiveness is completed/documented with the proper numerical value. The residents on this list will also be reviewed to assure that their pain has the appropriate medical assessment. 3) The policy for Pain Management was reviewed and revised to reflect professional standards in regards to numeric pain scales and medical assessment. The electronic MAR practice has been revised to require numeric pain scale information for all pain assessments and re-assessments. An inservice has been developed to educate all licensed nursing staff and medical provider staff on the revised policy and practice. The in-service department/ designee will be responsible for providing the education. 4) An audit tool has been created to assure that the facility is managing pain in accordance with the standard. The audits will review 2 random residents per neighborhood per month (34 per month total) for 3 months, then on an as needed basis. The audits will be completed by the Inservice Education/designee as overseen by the DON/designee. The Director of Nursing will review the findings of the audits at the QAPI committee meetings and will assume ultimate responsibility for F 697.