| 1051 |
MACON REHABILITATION AND HEALTHCARE |
115362 |
505 COLISEUM DRIVE |
MACON |
GA |
31217 |
2017-08-10 |
309 |
D |
0 |
1 |
4CBP11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, resident, and staff interviews, the facility failed to ensure one of 34 sampled residents (R#91) had received as needed (PRN) pain medications and appropriate assessments for pain. Findings Include: According to the Admission Record R#91 was re-admitted to the facility on [DATE]. Review of the [DIAGNOSES REDACTED].#91 had stage III pressure ulcer, stiffness of the joint, muscle weakness, lack of coordination, abnormal posture, and cerebral infarction (area of necrotic tissue in the brain). Review of the most recent quarterly Minimal Data Set ((MDS) dated [DATE] revealed under Section B0700 Makes Self Understood and B0800 Ability to Understand Others R#91 was understood by others and able to comprehend others. Review of Section C - Cognitive Patterns R#91 scored an 8/15 on the Brief Interview for Mental Status (BIMS) indicating R#91 was cognitively impaired. Section J0100. Pain Management revealed that R#91 did not received PRN medications or decline PRN medications, J0300. Pain Presence resident had not had pain or hurting during the last five days. Section M0300. Current Number of Unhealed Pressure Ulcers at Each Stage documented that R#91 had a stage III pressure ulcer. Review of the Care Plan initiated on 11/16/16 and revised on 8/9/17 (after stage II investigations) R#91 had a focus related to alteration in comfort related to right toe amputation, limited mobility, [MEDICAL CONDITIONS] and pressure wound to left heel. The pertinent interventions were, administer pain medications as ordered, observe for tolerance and effectiveness, assist with repositioning for increased comfort, monitor for signs/symptoms of pain every shift, observe for signs/symptoms of pain/discomfort such as facial grimacing, or change in behaviors. During an interview on 8/7/17 at 3:25 p.m., R#91 revealed both his feet hurt and he stated he has two sores and they, hurt like crazy. He discussed if he is receiving pain medication he cannot tell if it makes him feel better as he still has pain. During an observation and interview on 8/10/17 at 9:35 a.m., R#91 was observed having his left heel dressing changed. R#91 reported no pain during or after the treatment. The wound care nurse indicated R#91 was medicated prior to his treatment today but normally he did not receive any PRN pain medication. At 11:19 a.m. R#91 was asked if he was having any pain and he reported no. R#91 was observed moving his legs, grimacing, and grunting, when asked why he stated he was having pain in his legs, jumping all the time and they hurt. He indicated his pain was 10 out of 10 pain rating (0 being no pain and 10 being the worst pain) although he had just reported no pain. He discussed it takes one to two hours for the pain medication to help and sometimes it is not enough. During an interview with the Director of Nursing (DON) on 8/10/17 at 11:08 a.m., she reported that she sits with R#91 every morning and he has never complained to her about pain, but admitted she does not ask him directly about pain. She was present during the interview with R#91 and discussed with him if he thought his pain medication was effective, he responded, No it takes a while to work and even then I still have pain. During an interview with R#91's nurse Licensed Practical Nurse (LPN) PP on 8/10/17 at 10:45 a.m., reveal R#91 has not complained of pain to her. She further revealed she had heard R#91 informed the unit manager LPN FF he had reported pain to the new lady (meaning this surveyor) but he had not reported to any other staff. During an interview on 8/10/17 at 10:55 a.m., LPN FF revealed yesterday when she was talking with R#91 he had stated he had told the new lady his feet were hurting. LPN FF indicated she interviewed the CNA and nursing staff and R#91 does not usually complain of his pain or report his feet are hurting. She discussed if a resident did complain of pain and a PRN medication was available, staff were to give the medication and record it on the EMAR and in the Progress Notes. Review of the (MONTH) (YEAR) Physician order [REDACTED].#3 one tablet every six hours as needed for pain. Review of the (MONTH) (YEAR) Electronic Medication Administration Record (EMAR) revealed R#91 reported pain five times during this month. His pain rating was never higher than a two or a three and he reported pain on all three shifts that month. The EMAR revealed there was no documentation R#91 was offered a PRN pain medication during those five days, nor any documentation his pain had resolved. R#91's [MEDICATION NAME] was given as scheduled. Review of the (MONTH) (YEAR) Progress Notes revealed no documentation addressing R#91 complaints of pain. Review of the (MONTH) (YEAR) EMAR revealed R#91 reported pain four times during this month. His pain rating was never higher than a two or a three. R#91 was given PRN Tylenol once on 8/10/17 prior to his wound care although there was no numerical indicator of pain recorded. R#91's [MEDICATION NAME] was given as scheduled. Review of the (MONTH) (YEAR) Progress Notes through 8/9/17 revealed no documentation addressing R#91 complaints of pain. During an interview with the DON on 8/10/17 at approximately 11:50 a.m., she reviewed the (MONTH) (YEAR) and (MONTH) (YEAR) EMAR noting R#91 had complained of pain five times in (MONTH) and four times in August. She discussed if a resident complained of pain and a PRN medication was available, the nurses were to administer the medication, follow up on the effectiveness, and document the location of the pain and effectiveness in the Progress Notes. She indicated she had no explanation of why nursing staff had not addressed or administered a PRN medication on those days, but they should have addressed his pain and documented the outcomes. |
2020-09-01 |