Inadequate Pain Management for Resident with Vascular Wounds

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident who had recently undergone a below-the-knee amputation was not provided with adequate post-surgical pain management. The resident had a physician's order for Oxycodone 10 mg every four hours as needed for moderate pain, and acetaminophen scheduled every eight hours. The resident consistently reported significant pain, with pain levels ranging from 7 to 10, and had received 17 doses of Oxycodone prior to the incident. The care plan identified the resident as being at risk for pain due to the recent surgical procedure, with interventions including medication and repositioning. On the night of the incident, the resident experienced severe pain rated at 10 out of 10 and requested narcotic pain medication. However, the Oxycodone prescription had expired and was not renewed in a timely manner, resulting in no narcotic pain medication being available. The on-call nurse practitioner declined to renew the prescription during the night and instead ordered extra strength Tylenol, which the resident refused. As a result, the resident requested transfer to the hospital for pain management and was subsequently transported by EMS. Interviews with staff confirmed that the failure to renew the Oxycodone prescription led to the unavailability of the medication when the resident was in severe pain. The DON acknowledged that the prescription had expired and was not renewed, which directly resulted in the resident's transfer to the hospital for pain control. The facility's pain management policy defined pain management as alleviating pain to a level acceptable to the resident, but this standard was not met in this case.

Plan Of Correction

This Plan of Correction is being prepared and executed because it is required by the provisions of the State and Federal regulations and not because Kingston of Ashland agrees with the allegations and citations listed on the statement of deficiencies. Kingston of Ashland maintains that the alleged deficiencies do not individually or collectively jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as Kingston of Ashland's written credible allegations of compliance. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Kingston of Ashland reserves all possible contentions and defenses in any civil or criminal actions or proceeding. Please accept the date of correction 4/17/2025 as the facility's credible allegation of compliance. F697 Resident #93 no longer resides in the center. Resident #93 was sent to the ER on 3/7 and script for Percocet obtained at that time. Nurse practitioner #339 was provided education on 4/3 and 4/4 on the pain assessment and management policy, controlled substance prescription policy, and receiving controlled substances policy. The Director of Nursing or designee will review current residents on narcotic pain medications to ensure that the narcotic medication regimen is effective for treating pain and that the narcotic pain medications are available for use. This will be completed on or before 4/17/2025. Issues identified will be addressed at the time of discovery. The Director of Nursing or designee will educate licensed nurses and Certified Medication Aides on the controlled substance prescription policy and receiving controlled substance policy, which includes reordering of controlled medications, on or before 4/17/2025. The Director of Nursing or designee with educated licensed nurses on the pain assessment and management policy on or before 4/17/2025. The Director of Advanced Nurse Practitioners will educate the nurse practitioners on the controlled substance prescription policy and receiving controlled substance policy, which includes reordering of controlled medications, on or before 4/17/2025. The Director of Nursing or designee will complete an audit on 5 residents weekly for 4 weeks that receive narcotic pain medications to ensure that the narcotic medication regimen is effective for treating pain and that narcotic pain medication is available for use. The results will be presented to the QAA committee for review and consideration for further corrective actions.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain the availability of ordered pain management medications for a resident, leading to a deficiency in providing safe and appropriate pain management services. Resident #33, who was admitted with multiple diagnoses including acute respiratory failure, cellulitis, dysphagia, and chronic congestive heart failure, was cognitively intact and experienced mild depression. The resident had orders for a Fentanyl patch to be changed every 72 hours and Oxycodone as needed for pain. However, the resident reported experiencing continuous pain and went without the Fentanyl patch for 10-12 days due to issues with prescription refills. The March 2025 medication administration record indicated that Resident #33 was without a Fentanyl patch from March 9 to March 14. A progress note from March 6 documented that RN #47 contacted the pharmacy for a refill, but was informed that a new prescription was needed. Despite a request being placed on the physician's medication refill voicemail, the facility did not obtain a current order from the physician until March 14. The Director of Nursing confirmed the lapse in obtaining the necessary prescription, resulting in the resident not receiving the Fentanyl patch during this period.

Penalty

Fine: $44,825126 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide timely and appropriate pain management for two residents, Resident #6 and Resident #7, as identified through interviews, observations, and record reviews. Resident #7, who was admitted with diagnoses including diabetes mellitus, a stage III pressure ulcer, and chronic pain, experienced significant pain that was not adequately addressed during care. Despite receiving scheduled pain medications, Resident #7 reported severe leg pain during an interview and was observed to be in distress during a dressing change, with no additional pain relief interventions offered by the staff at that time. Resident #6, admitted with conditions such as cerebral infarction and hemiplegia, also experienced inadequate pain management. The resident reported severe shoulder pain following an incident with a Hoyer lift, which was not documented in the facility's incident log. Despite a high pain rating and complaints of pain affecting daily activities, there was a delay in obtaining an x-ray and providing appropriate pain relief. The resident's pain was not adequately assessed or managed, leading to prolonged discomfort and anxiety. The facility's policy on pain assessment and management, revised in October 2022, outlines procedures for identifying and addressing pain, including the use of both pharmacological and non-pharmacological interventions. However, the facility failed to adhere to these procedures, resulting in inadequate pain management for the residents. The lack of timely assessment and intervention for acute pain episodes contributed to the deficiencies identified in the report.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to administer pain-relieving medications as ordered for a resident with chronic pain conditions, including Crohn's disease and intervertebral disc degeneration. The resident, who had intact cognition, was supposed to receive hydromorphone every four hours as needed for pain. On the day in question, the Assistant Director of Nursing (ADON) was working the floor due to a staff call-off and was unfamiliar with the medication administration on that unit. The ADON did not administer the pain medication in a timely manner, causing the resident to wait at least an hour for relief, despite the resident's request and visible distress. The incident was investigated after concerns were raised by staff, residents, and family members about the delay in medication administration. The Unit Manager took over the medication administration from the ADON and provided the resident with the overdue hydromorphone. The facility's policy on pain management and assessment requires staff to ensure residents receive treatment and care in accordance with professional standards, which was not adhered to in this case. This deficiency was investigated under a specific complaint number, indicating non-compliance with the facility's pain management protocols.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate pain management for two residents, resulting in actual harm. Resident #273 was admitted with a history of chronic pain and an active order for Norco, an opioid pain medication, from a previous facility. However, upon admission, the facility did not continue the Norco order, and the resident was not evaluated by a physician in a timely manner. As a result, the resident experienced severe, constant pain that limited his functional abilities and participation in therapy. Despite expressing pain and refusing Tylenol, which was ineffective, the resident did not receive appropriate pain management until several days later when Tramadol was prescribed. Resident #66, who had a history of hemiplegia and other conditions following a cerebral infarction, also experienced inadequate pain management. The resident's care plan included interventions for pain, but there were multiple instances where pain assessments were not conducted, and pain medication was not administered as needed. The resident's pain was documented during therapy sessions, where it was noted to limit functional activities, yet the facility failed to consistently address and manage the pain effectively. Observations revealed the resident exhibited signs of pain during transfers and therapy, but these were not adequately documented or addressed by the nursing staff. The facility's failure to implement a comprehensive and individualized pain management program for these residents was evident in the lack of timely physician evaluation, inadequate pain assessments, and inconsistent administration of pain medication. The facility's pain policy, which required assessments and interventions for identified pain, was not followed, leading to prolonged discomfort and limited functional abilities for the affected residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to effectively manage the pain of a resident following an unwitnessed fall, which resulted in a left subcapital femoral neck fracture. The incident occurred when the resident fell in her room and reported left leg and knee pain to two LPNs. Despite receiving one dose of PRN Tylenol, there was no documentation on the medication administration record (MAR), and the resident continued to exhibit signs of pain, such as yelling out and facial grimacing. The on-call Nurse Practitioner ordered an x-ray and an ice pack for pain, but no additional pain medications or interventions were provided until the resident was sent to the hospital approximately 19 hours later. The resident, who had a history of major depressive disorder, generalized anxiety disorder, and atrial fibrillation, was at risk for falls and had a recent pain assessment indicating no pain in the last five days. After the fall, the resident expressed pain at a level of six out of ten and showed nonverbal signs of pain. The fall investigation revealed that the resident attempted to transfer and ambulate herself, leading to the fall due to weakness and poor safety awareness. Despite these findings, there was no documentation of pain levels on the MAR, and the resident's pain was not adequately addressed. Interviews with staff and review of facility policies highlighted the lack of appropriate pain management. The Director of Nursing confirmed that the resident showed multiple signs of pain after the fall, but there was no documentation of pain medications being administered before the resident was sent to the hospital. The facility's pain management policy emphasized the need for timely assessment and intervention for acute pain, which was not followed in this case, leading to the resident's prolonged discomfort and eventual need for surgical intervention.