| 424 |
ST. JOSEPH VILLA NURSING CENTER |
285078 |
2305 SOUTH 10TH STREET |
OMAHA |
NE |
68108 |
2018-02-12 |
697 |
G |
1 |
1 |
B6BN11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on observation, record review and interview; the facility staff failed to implement and evaluate the effectiveness of the pain management program for 1 (Resident 156), and failed to evaluate the effectiveness of as needed pain medications for 1 (Resident 256) of 5 sampled residents. The facility staff identified a census of 170. Findings are: [NAME] Record review of a Face Sheet dated 1-24-18 revealed Resident 156 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 156's Minimal Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) signed as completed on 2-07-2018 revealed the facility staff assessed the following about Resident 156: -Brief Interview of Mental Status (BIM'S) was a 15. According to the MDS Manuel, a score of 13 to 15 indicate intact cognition. -Required Limited assistance with bed mobility, transfers, eating, toilet use and personal hygiene. - No pain issues were identified for Resident 156. Record review of Resident 156's Comprehensive Care Plan (CCP) dated 1-27-2018 Resident 156 had a problem area of pain. The goal identified for Resident 156 was to be able to verbalize or demonstrate minimal pain or discomfort. Interventions to manage Resident 156's pain included administering pain medication and evaluating the effectiveness, assess for non verbal signs of pain such as guarding, moaning and grimacing. Assessing pain characteristics, asking the resident to be specific regarding the duration, location and the quality of the pain. Medicate and offer to medicate for pain prior to physical activities such as Activities of Daily Living (ADL's) or Therapy. Offer non-pharmaceutical means of relief, such as, repositioning, elevation of extremities on pillows, relaxation-quite music, and 1 to 1's. Record review of Nursing Assessment and Re-Admission sheet dated 1-15-2018 revealed Resident 156 had pain to a leg, foot, Shoulder, hip and back pain described as stabbing and shooting pain. The relieving factor was the administration of pain medication. Record review of NAAR dated 1-30-2018 revealed Resident 156 had leg and foot pain with the relieving factor was the administration of pain medication. Record review of Resident 156's Nurse's Notes (NN) dated 1-31-2018 with a time of 9:00 PM revealed Resident 156 refused to get out of bed, c/o (complained of) Pain). According to the NN dated 1-31-2018, pain medication was given. Record review of Resident 156's medical record revealed there was no evidence the facility staff had evaluated the effectiveness of the pain medication. Record review of Resident 156's NN dated 2-1-2018 with a time of 5:30 AM revealed Resident 156 was crying and expressing frustration c/o severe pain to bilat ( both) LE's ( lower extremities) with pain medication being administered. Record review of Resident 156's record that included the Medication Administration Record [REDACTED]. Record review of Resident 156's NN dated 2-2-2018 with the time identified as 8:00 AM revealed Resident 156 continues to cry loudly and to refuse cares. Record review of Resident 156's MAR for 2-2-2018 revealed at 9:50 AM pain medication and an anti-anxiety medication was administered to Resident 156. Further review of the MAR indicated [REDACTED]. Record review of Resident 156's NN dated 2-3-2018 with a time identified as 5:00 AM revealed Resident 156 was difficult to reposition in bed and change an adult brief related to Resident 156 yelling out in pain. Further review of Resident 156's NN dated 2-3-2018 at 5:00 AM revealed Resident 156 yelled out pain description, I hurt all over, its sharp pain. The NN dated 2-3-2018 at 5:00 AM revealed Resident 156 continued to cry and yell out with all cares with Resident 156 stating just let me die. Observation on 2-07-2018 at 8:45 AM revealed Resident 156 needed to use the bathroom. Registered Nurse (RN) C and Nursing Assistant (NA) D came into Resident 156's room and Resident 156 reported the need to use the bathroom. Resident 156 chose to use a bed pan instead of using the bathroom due to increased anxiety for the use of a mechanical lift. NA D with the assistants of another NA started to roll resident to the side. Resident 156 was observed to have facial grimacing reporting (gender) knee hurt and reported a pain level of an 8 to 9 on a scale of 0 to 10 with 10 being the worst pain. RN C asked Resident 156 if Resident 156 wanted pain medication with Resident 156 stating, yes. RN C obtained Resident 156's pain medication and administered to Resident 156. Observation with RN C on 2-07-2018 at 9:35 AM revealed NA D with another NA prepared to transfer Resident 156 using a mechanical lift. NA D placed the sling for the transfer under Resident 156 requiring Resident 156 to roll side to side. Resident 156 yelled out, oh that hurts my back. NA D explained the task of the transfer to Resident 156. NA A attached the sling to the mechanical lift and started to lift Resident 156 up. Resident 156 started to yell Oh my back, my back and started to cry. Resident 156 reported it feels like my back is broke. NA D started to raise Resident 156 up with Resident 156 yelling oh that hurts, stop. let me rest. Resident 156 stated put a sock in my mouth so I don't scream. On 2-07-2018 at 9:54 AM an interview was conducted with NA D. During the interview, NA D reported Resident 156 is always painful. NA D reported Resident 156 pain has been getting worse and this had been reported to the nurses. NA D reported Resident 156 is more painful when moved and that Resident 156's pain seems to be getting worse. On 2-07-2018 at 11:15 Am an interview was conducted with the Medical Records Manager (MRM). During the interview the MRM reported Resident 156 did not have a pain management flow sheet started for Resident 156. On 2-07-2018 at 1:25 PM an interview was conducted with RN C. During the interview when asked if Resident 156 had been pre-medicated prior to the ADL's being completed. RN C stated no, further reported Resident 156 should have been pre-medicated. When asked what Resident 156's acceptable pain level was, RN reported not knowing what was acceptable to Resident 156. On 2-08-2018 at 7:56 AM an interview was conducted with Resident 156 related to Resident 156's pain management. During the interview Resident 156 reported the goal for acceptable pain level was a 5 based on a scale of 0 to 10 with the 10 being the worst pain. Resident 156 reported (gender) pain level are between and 8 and 9 with movement. On 2-08-2018 at 10:45 AM an interview was conducted with Licensed Practical Nurse (LPN) [NAME] During the interview LPN G reported that all pain medication should be evaluated for the effectiveness. Record review of an undated Policy and Procedure for Pain Assessment and management revealed the following information. -Purpose: All Residents will be assessed for pain and identified by nursing staff. Residents with pain will receive individual interventions aimed at reducing chronic and/or acute discomfort utilizing current standards of practice for pain control. -Procedure: -2. develop an individualized care plan for pain management. -3. Pain Management Flow Sheet will be placed in each residents medication record for assessment and documentation of intermittent and breakthrough pain. -4. Pain assessment will be done using the 0 to 10 pain scale based on the residents cognitive status. -6. Interventions to treat residents pain will be implemented to manage pain effectively. -7. Evaluate effectiveness of PRN (as needed) [MEDICATION NAME] within an hour of time administered and document effectiveness on the back of the MAR indicated [REDACTED]. B. Resident 256 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. In an interview on 2/7/18 at 2:21 PM, Resident 256 reported having pain at a level 10 (pain rating scale of 1-10) and reported having received a pain pill an hour ago. Resident 256 reported not getting relief from pain. A review of Resident 256's 2/2018 Medication Administration Record [REDACTED]. A review of Narcotic count record for Resident 256 revealed Resident 256 received [MEDICATION NAME] 5 mg 19 times between 2/1/18 and 2/7/18. A review of 2/2018 Resident 256 Medication Administration Record [REDACTED]. A review of the back side of the Medication Administration Record [REDACTED]. A review of Resident 256 PRN Pain Management Flow Sheet revealed documentation of [MEDICATION NAME] given 4 times as follows: 1 time on 2/4/18, twice on 2/5/18 and once on 2/7/18. The flow sheet identifies pain location, pain level, [MEDICATION NAME] given, and if [MEDICATION NAME] is effective. In an interview on 2/8/18 at 10:41 AM, Licensed Practical Nurse M reported pain flow sheet is to be completed when a resident asks for a pain medication. In an interview on 2/8/18 at 12:10 PM, Staff Development Registered Nurse reported no other PRN Pain Management Flow Sheet could be located for Resident 256. A review of undated policy titled Pain Assessment and Management revealed the following: -the Pain Management Flow sheet will be used for assessment and documentation of intermittent and breakthrough pain. -The effectiveness of PRN [MEDICATION NAME] will be evaluated within an hour of administration and documented on back of Medication Administration Record [REDACTED] |
2020-09-01 |