| 209 |
ROSE BLUMKIN JEWISH HOME |
285059 |
323 SOUTH 132ND STREET |
OMAHA |
NE |
68154 |
2016-12-01 |
309 |
G |
0 |
1 |
W3MZ11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE 175 NAC 12-006.09 Based on observation, record review and interview; the facility staff failed to re-evaluate pain indicators and implement interventions to manage pain for 1 (Resident 112) of 1 residents reviewed. The facility staff identified a census of 86. Findings are: Record review of Resident 112's Minimum Data Set ( MDS, a federally mandated assessment tool used for care planning) signed as completed on 9-26-2016 revealed the facility staff assessed the following about the resident: -Brief Interview for Mental Status (BIMS) score was a 3. According to the MDS Manual, a score of 0 to 7 indicated severe cognition impairment. -Independent with bed mobility. -Supervision with personal hygiene. -Limited assistance with on and off the unit. -Extensive assistance with dressing and toilet use. -Received as needed (PRN) pain medication or was offered and the resident declined the medication. Record review of Resident 112's Comprehensive Care Plan (CCP) dated 6-13-2016 revealed Resident 112 had back pain. The goal for Resident 112 was that Resident 112 would rate pain below a 4 on the pain scale. Typed in interventions on the CCP were to balance rest and activity, use numeric scale to rate pain, Tylenol and [MEDICATION NAME] (pain medication) PRN.[MEDICATION NAME] (pain medication) PRN. Further review of Resident 112's CCP dated 6-13-2016 revealed a hand written entry update that Resident 112 received an x-ray due to increased pain and the update dated 10-26-2016 that Resident 112 was to receive Tylenol routine for back pain. Observation on 11-30-2016 at 8:02 AM of personal care for Resident 112 revealed Nursing Assistant (NA) [NAME] and NA F washed hands and donned gloves. Resident 112 was observed to be in bed. Resident 112 yelled out Oh that hurts and was heard to moan and groan as NA F started to cleans the front peri area. Resident 112 continued to yell out stop at NA F and then started to hit at NA F. NA [NAME] assisted Resident 112 into a right laying position for further cleaning. Resident 112 yelled out Your killing me, Oh God Help me, it hurts, Daddy Daddy, oh boy that hurts. NA [NAME] and NA F positioned Resident 112 onto a back laying position and pulled up Resident 112's clothing. When asked by NA F if (gender) wanted to go to breakfast, Resident 112 reported, no. NA [NAME] and NA F did not stop the procedure when Resident 112 complained of pain to report it to the charge nurse. On 11-30-2016 during the observation of care at 8:02 AM, NA [NAME] said Resident 112 was always in pain. Observation on 11-30-2016 at 1:10 PM of Resident 112 being transferred from a wheelchair to the bed revealed NA [NAME] and NA F placed a transfer belt around Resident 112. Both NA [NAME] and NA F explained the transfer task to be completed to the resident. NA [NAME] and NA F began to transfer Resident 112 from the wheelchair and Resident 112 yelled out in pain stating ouch, that hurts and was transferred into bed. NA [NAME] and NA F pulled down Resident 112 pants and positioned the resident onto the resident ' s right side. During the repositioning, Resident 112 yelled out Oh it hurts, help me god, don't move me. NA [NAME] and NA F completed the personal care. An interview was conducted on 11-30-2016 at 1:10 PM after the personal care was completed. When attempting to ask Resident 112 to rate the pain, Resident 112 stated little bit, little bit with furrowed brows. Resident 112 was not able to state a number on a scale of 0 to 10. An interview on 11-30-2016 at 2:01 PM was conducted with Licensed Practical Nurse (LPN) B. During the interview, LPN B reported that NA [NAME] and NA F had informed (gender) about Resident 112's pain. LPN B reported Resident 112 had identified the pain as a little bit. When asked if LPN B had evaluated Resident 112's pain after being notified, LPN B stated no. Record review of The Facility Pain assessment and Treatment Program Policy and Procedure dated 7-2013 revealed the following information: -Policy: All residents will have their pain recognized, assessed and treated. Pain may manifest itself as verbal expression of pain, moaning, sleep disturbances, agitation, rocking, grimacing, withdrawal, crying, and guarding of affected area(s). -Procedure: -1. The resident will be assessed for pain by the licensed nurse at admission, re-admission, quarterly and as needed. -5. Staff will continue to monitor for verbal and nonverbal signs of pain. It may be necessary to ask the resident are you having pain?, are you comfortable?, do you have discomfort or do you ache anywhere?. The pain assessment scale will be utilized to rate the severity of pain. -6. Information regarding the resident's pain, interventions and management will be included in the resident's plan of care. This will be reviewed and modified needed. -treatment plan: [REDACTED] -1. treatment of [REDACTED]. -2. Non-Pharmacological interventions can include repositioning, music, relaxation, distraction, exercise, physical or occupational therapy and application of ice or heat. -4. It may also be necessary to administer pain medication prior to certain activities such as physical or occupational therapy or medical procedures. -5. The licensed nurse will notify the physician if the residents is not experiencing relief with the current treatment plan or are experiencing a new acute onset of pain and pain is interfering with their comfort and/or functional status. The resident will be placed on triggered charting until the resident is free of pain or the pain controlled within the resident's stated acceptance level The facility staff did not provide additional information prior to survey exit. |
2020-09-01 |