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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 23, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff observation, interviews and record review conducted during an abbreviated survey (NY 408), the facility did not ensure that pain management was provided to a resident who required such services consistent with professional standards of practice. This was evident in one out three residents (Residents #1) sampled. Specifically, Resident #1 reported to Certified Nursing Assistant #1 on 02/09/2024 at 10:10 AM that they were unable to stand and that they had pain. Resident #1 was transferred, by Licensed Practical Nurse #1 and Certified Nursing Assistant #1, before being assessed by Registered Nurse Supervisor #1 and before pain medication was administered. Resident #1 was transferred to the hospital on [DATE] and was diagnosed with [REDACTED]. There was no documented evidence of pain assessment or that pain medication was administered on 02/09/2024 prior to Resident #1 being transferred to the hospital. The findings include: The facility Policy and Procedure title Pain Assessment, Education and management dated on 05/2024, documented it is the policy of the facility to assess and manage resident's pain upon admission/readmission and continually throughout their stay to assure the highest level of pain control and resident comfort. Pain assessment should be performed by a Registered Nurse using the Pain Assessment Tool. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, an assessment tool) dated 12/08/2023 documented Resident #1 had Severe Impaired Cognition. Resident #1 was independent in bed mobility and transfer. A physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. There was no documented evidence of pain assessment. The facility's Summary of Investigation dated 02/12/2024, revealed Certified Nursing Assistant #1 provided care to Resident #1 on 02/09/2024 at approximately 10:30 AM. Resident #1 was unable to stand when Certified Nursing Assistant #1 was assisting them to stand up. Certified Nursing Assistant #1 immediately notified Licensed Practical Nurse #1, who responded and notified Registered Nursing Supervisor # 1. Registered Nursing Supervisor #1 went to Resident #1's room and Resident #1 was observe sitting on a chair. On assessment Resident #1 was unable to bear weight on their left lower extremity. Resident #1 complained of pain in their left hip and groin area. Resident #1 left lower extremity was kept immobilized. Resident #1 was transferred (back) to bed and a completed body assessment was done. Resident #1 had a slight swelling to their left hip area. Resident #1 was transferred to the hospital for further evaluation. A Hospital Record dated 02/10/2024 revealed a Computed Tomography Scan was done in the hospital and showed an acute Pelvic fracture. The facility's investigation concluded there was no evidence to support abuse, neglect, or mistreatment. The investigation also concluded Resident #1 is independent and moves about frequently, therefore, Resident #1 could have fractured their pelvis during an unassisted transfer. Resident #1 has a history of osteopenia and prior falls with status [REDACTED]. A Nursing Progress note, by Registered Nursing Supervisor #1, dated 02/09/2024 at 12:25 PM documented they were notified, by Licensed Practical Nurse #1, Resident #1 had difficulty standing. Assessment revealed Resident #1 had difficulty bearing weight and expressed pain to their left hip and groin area. Resident #1 denied falling. Resident #1 was lifted manually from standard chair and was put back in bed. The Medical Doctor was notified and ordered Tylenol 650 milligram by mouth every hour as needed and a STAT x-ray to bilateral hip and pelvis. A Transfer Note dated 02/09/2024 at 2:24 PM, by Registered Nurse #1, documented Resident #1 was being transferred to the hospital to ruled out fracture to bilateral hip. Resident #1 was unable to bear weight. Family notified. A hospital Inpatient Discharge Summary dated 02/15/2024 documented Resident #1 was admitted on ,[DATE]/ 2024. A Computed Tomography Scan was done on 02/09/2024 of the abdomen and pelvis. The result showed the bones were osteopenic (a lower-than normal bone mass or bone mineral density). Acute fractures of the left superior and inferior pubic ramus (a pair of bone at the front of the pelvis that make up part of the hip). Acute, minimally displaced position of the right superior pubic ramus. Also documented - the bones appeared to be demineralized, limiting evaluation. There was a chronic posttraumatic deformity of the proximal left femur. A long intramedullary nail (a metal rod forced into the medullary cavity of a bone) with distal interlocking screw in place in the left femur. No acute displace fracture or dislocation in the hips. There were [MEDICAL CONDITION] changes of the hips. During an interview on 12/03/2024 at 12:00 PM, Certified Nursing Assistant #1 stated at approximately 10:35 AM on 02/09/2024 they asked Resident #1 to stand and while Resident #1 was attempting to stand up, Resident #1 reported that they are feeling pain and pointed towards their left knee. Resident #1 also reported they were unable to put weight on their left leg. Certified Nursing Assistant #1 stated they assisted Resident #1 to sit on the bed and immediately called Licensed Practical Nurse # 1. Certified Nursing Assistant #1 stated Licensed Practical Nurse #1 came to Resident #1's room and spoke with Resident #1 in Spanish. Certified Nursing Assistant #1 stated Licensed Practical Nurse #1 instructed them to assist them (Licensed Practical Nurse #1) in transferring Resident #1 from the bed to the chair. Certified Nursing Assistant #1 stated Licensed Practical Nurse #1 notified Registered Nurse Supervisor #1 after Resident #1 was transferred to the chair. During an interview on 12/02/2024 at 12:30 PM, Licensed Practical Nurse #1 stated on 02/09/2024 at approximately 10:30 AM Resident #1's assigned Certified Nursing Assistant #1 called them to Resident #1's room stating Resident #1 was not themself and that Resident #1 complained of pain to their left leg and was unable to stand. Licensed Practical Nurse #1 stated when they arrived in Resident #1's room, Resident #1 was sitting on the edge of their bed and bed linen was wet. Licensed Practical Nurse #1 stated they assisted Certified Nursing Assistant #1 to transfer Resident #1 to sit on the chair in their room. Licensed Practical Nurse #1 stated that Resident #1 was rubbing their left hip and thigh area and complained of pain. Licensed Practical Nurse #1 stated they checked Resident #1's feet but did not see anything. Licensed Practical Nurse #1 stated they did not check Resident #1's hip because Resident #1 was wearing pants. Licensed Practical Nurse #1 stated they immediately notified Registered Nurse Supervisor # 1. Licensed Practical Nurse #1 stated they transferred Resident #1 from the bed to the chair before calling Registered Nurse Supervisor # 1. Licensed Practical Nurse #1 stated the Medical Doctor was notified Tylenol 325 milligram two tablets to give STAT and then 325 milligram three times a day. Licensed Practical Nurse #1 stated they gave Resident #1 the pain medication but did not sign for the medication at the time of administration. During an interview on 12/02/2024 at 1:12 PM, Registered Nurse Supervisor #1 stated on 02/09/2024 at approximately 10:35 AM, Licensed Practical Nurse #1 notified them that Resident #1 was unable to bear weight on their left leg. Registered Nurse Supervisor #1 stated they went to Resident #1's room and observed Resident #1 sitting on a chair pointing to their hip. Registered Nurse Supervisor #1 stated they put Resident #1 back in bed and immediately assessed Resident #1 whose left hip was swollen. Registered Nurse Supervisor #1 stated there were no discoloration or bruising on Resident #1's hip. Resident #1 state | Plan of Correction: ApprovedJanuary 21, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #1 was identified as being directly affected by the alleged gap in practice. The facility did not ensure that pain management is provided to resident who require such services consistent with professional standards of practice and the comprehensive person-centered care plan. - An investigation was conducted and concluded that there was no evidence to support that abuse, neglect or mistreatment may have occurred. - Resident #1 was transferred to the hospital on [DATE] and readmitted to Kings Harbor on 2/15/ 24. - Upon resident #1 readmission from the hospital: - A Pain Assessment was completed - Resident #1 was evaluated by PMD and Tylenol 325mg q 6 hours for 14 days was ordered for pain management. - Care Pan #131A Pain Management was updated. - Resident #1 was monitored for pain and the effectiveness of pain management. - LPN #1 was educated on medication administration and documentation. - RN #1 was educated on pain assessment, pain management and updating Care Plan when change in resident condition is noted. - CNAs, LPNs and RNs of the Manor service were educated on reporting new onset of pain and deferring transfer/movement of resident prior to assessment by RN. 2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The facility respectfully states that all residents have the potential to be affected by the alleged gap in practice. All residents with new onset of pain in the last 30 days will be reviewed by the RNM/RNS to ensure that a pain assessment is conducted, PMD was notified, appropriate pain management was implemented, and pain care plan was updated. In the event that non-compliance was identified, it will be immediately corrected to comply with F 697. Responsible Party: RNM/RNS 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not occur? An Ad Hoc QA/PI Meeting with the Administrator, DON, Medical Director, Director of QA/PI, and Staff Development was held to discuss the systemic changes that will be made to ensure that the deficient practice does not occur. 1. The Policy and Procedure for Pain Assessment, Education and Management was reviewed to assure compliance with F697 by the Administrator in conjunction with the Director of Nursing, Director of QA/PI and Medical Director and revised accordingly. The change in policy include ?ôPain assessment and Pain Management care plan update shall be performed:?Ø a. On admission/re-admission b. Quarterly and Annually for CCP Meeting c. Upon significant change in residents condition d. Upon any incident or accident as part of the assessment of the resident e. For any new complaint of pain identified by resident or staff f. Prior to initiation of a pain medication regime or change in pain medication regime g. Upon a change in the residents pain medication h. At any other time based on nursing or physician assessment Responsible Party: Administrator, DON, Medical Director, Director of QA/PI 2. Inservice education will be provided by the Inservice Coordinator/designee to all RNs and LPNs on pain assessment, management and care plan update. Highlights of the lesson plan include: - It is the policy of Kings Harbor to assess and manage residents pain upon admission/readmission and continually throughout their stay to assure the highest level of pain control and resident comfort. - When and how to perform pain assessment - Communicating with the medical provider when pain is identified - Documentation of pain assessment and management - Updating pain care plan as indicated in the Pain policy Responsible Party: Inservice Coordinator/Designee 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? 1. An audit tool will be developed to monitor the facilitys compliance with ensuring that all residents with new onset of pain are assessed and managed and that all appropriate documentations are completed. Responsible Party: QA/PI 2. All residents with new onset of pain will be reviewed to ensure that they are assessed, and appropriate management is implemented weekly x 4 weeks and then monthly for 3 months, using the new audit tool to ensure compliance. Any identified issues will be immediately addressed and shared at the Morning Meeting. Responsible Party: Nursing Team Leaders/ADON 3. The results of the pain audits will be analyzed for trends and patterns. Responsible Party: QA/PI Coordinator 4. Results of the pain audit will be presented and discussed at the facility monthly by QA/PI. Responsible Party: QA/PI Coordinator 5. Date for correction and the title of the person responsible for correction of deficiency. Deficiency will be corrected by (MONTH) 21, 2025, 60 days from the survey exit date. Person responsible for correction is the Administrator. |