| 4846 |
SIDNEY CARE AND REHABILITATION CENTER, LLC |
285113 |
1435 TOLEDO STREET |
SIDNEY |
NE |
69162 |
2018-03-06 |
697 |
H |
1 |
1 |
9WK311 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.09D Based on observations, record reviews and interviews; the facility failed to ensure that 1) pain assessments were completed and pain was managed for one current sampled resident related to a dislocated shoulder and chronic headaches related to a [DIAGNOSES REDACTED] (Resident 176), 2) pain assessments were completed with pain levels rated severe for one current sampled resident (Resident 11) and 3) assessments were completed and interventions were in place to relieve ongoing pain related to positioning in the wheelchair for one current sampled resident (Resident 22). The facility census was 27 with 16 current sampled residents. Findings are: [NAME] Review of the Admission Record revealed that Resident 176 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Progress Notes, dated 2/25/18 at 12:00 PM revealed that the resident was seated on the toilet and upon rising stated ow and pointed to bicep area. The resident requested spouse be called. Spouse called and stated that the resident's shoulder was dislocated and requested the resident be sent to the emergency room per ambulance. Resident was assessed for pain and was transferred to the hospital per ambulance. Further review revealed that at 2:55 AM, the resident returned to the facility with no documentation of an assessment of the left shoulder until 2:59 PM. Review of the hospital emergency room report, dated 2/25/18 at 12:56 AM, revealed the following including: - Presenting problems included history of [MEDICAL CONDITION] and brain surgery on 2/12/18, spouse received a call from the nursing home that the resident was having severe pain in the left shoulder, found that the left shoulder was dislocated and the left hand was blue, spouse reduced the left shoulder and restored circulation to the left arm. Interview with the resident's spouse on 2/28/18 at 7:45 AM revealed concerns related to pain management. The spouse stated that the resident was not always reliable with communication, when asked if having pain will say no when the resident means yes. Nonverbal symptoms of pain need to be utilized, frowning, shaking head, or grimacing. The spouse stated that the resident had a long history of frequent headaches since diagnosed wih the [DIAGNOSES REDACTED] and typically took Tylenol at least a couple of times a day for lesser pain and [MEDICATION NAME] daily for more severe headaches. The spouse stated that would put hands up and the resident could point to a finger to express the intensity of pain. The spouse was concerned that the resident was having pain that wasn't identified by the staff and medications were not being administered when needed. Review of the care plan, initiated on 2/26/18, revealed no care plan to address pain. Review of the Medication Administration Record, [REDACTED]. Further review revealed that no pain medication was administered until 2/26/18. Further review of the Progress Notes included the following: - 2/26/18 at 9:00 AM [MEDICATION NAME] administered for complaints of pain all over rated 7-10 on the pain scale The pain scale is based on 1 - 10 with 8-10 considered extreme pain; - no documentation of where the pain was located or other interventions in place to manage the pain; - 2/26/18 at 10:33 AM - medication was effective with no further documentation; - 2/26/18 at 10:15 PM - medication was given pain medication earlier for headache; - 2/27/18 at 12:27 AM - [MEDICATION NAME] given for complaints of a headache, no further assessment documented including intensity or other care provided to relieve the headache; - 2/27/18 at 3:06 AM - resident states no pain; - 2/27/18 at 6:03 AM - [MEDICATION NAME] administered for pain , no documentation of the location or intensity; - 2/27/18 at 7:17 AM - medication was effective with no further assessment. Interview with the DON (Director of Nursing) and the Nurse Consultant on 3/5/18 at 8:50 AM confirmed that there was no assessment of the resident's left shoulder injury on 2/24/18 including causal factors, intensity of the pain, or that pain medication was administered to relieve the pain. Further interview confirmed that assessments should have been completed and documented related to the resident's headaches, including non verbal symptoms of pain, to ensure pain was effectively identified and managed to meet the resident's needs. B. Review of the Admission Record revealed that Resident 11 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview with the resident on 3/1/18 at 11:30 AM revealed that knee has been killing me and went to the doctor and has an infection in the knee. Review of the care plan, target date 4/28/18, revealed that the resident required assistance with activities of daily living including transfers, mobility, and assess for non verbal indicators of pain and encourage to verbalize pain and discomfort. Further review revealed no care plan to address actual pain and interventions to relieve pain. Review of the Medication Administration Record, [REDACTED]. Further review revealed that in addition [MEDICATION NAME] (narcotic [MEDICATION NAME]) was administered on 2/12/18 at 10:47 AM for pain rated 8, on 2/21/18 at 11:31 AM for pain rated 10 and on 2/27/18 at 12:47 PM for pain rated 10. Further review revealed that the medications were documented as effective. Interview with the DON on 3/5/18 at 3:45 PM revealed that no further assessments were completed or documented to include causal factors of pain, numerical rating to evaluate pain relief after pain medications were administered and non pharmacological interventions in place to prevent or to relieve pain. Further interview confirmed that assessments and follow up should be done to ensure that the resident's severe pain was managed to meet the resident's needs. C. Record Review of Resident 22's Admission Rcord printed on 2/28/18 revealed an admitted to the facility on [DATE]. Observation on 02/27/18 at 9:00 a.m. revealed Resident 22 was sitting in their wheelchair in their room placing clothing items in a dresser and Resident 22 verbally complained about back pain. Observation 02/28/18 at 10:30 a.m. revealed the resident was in the hallway sitting in their wheelchair and Resident 22 was in a slouching position in the wheelchair. Resident 22's back was not against the back of the wheelchair. Record Review of Resident 22's progress note completed by SSD ( Social Services Director) on 02/06/18 at 15:01 verified that Resident 22 had voiced concerns about the wheelchair. Record Review of Resident 22's MDS (Minimum Data Set) identified the resident had occasional pain and it was rated at an 8 on a scale of 0-10. Record Review of Resident 22's Care plan revealed that Resident 22's pain would be at an acceptable level through the next review. The care plan was revised on 2-21-18. Interventions included adjustments made to pain medication, Administer medication as ordered, monitor pain level per pain scale, if pain level not tolerable, notify PCP (Primary Care Physician) for medication adjustment or change. Interview on 02/27/18 at 9.00 a.m. with Resident 22 revealed the resident's wheelchair did not fit the resident correctly and it caused Resident 22 back pain. Interview on 02/28/18 at 10:00 a.m. with Resident 22 revealed when the resident was sitting in the wheelchair there were times that the resident experienced back pain and butt pain. Resident 22 reported the chair was causing the pain. Interview on 03/05/18 at 1:55 p.m. with the SSD ( Social Services Director) confirmed that Resident 22 complained about the wheelchair causing pain and requested to have the wheelchair re-evaluated. The SSD reported it was unclear where PT (Physical Therapy) was with this process but was also unclear who was responsible for the follow up on the wheelchair which may be causing the resident pain. Interview on 03/05/18 at 2:16 p.m. with PTA (Physical Therapy Assistance)-K verified they were not aware about Resident 22's wheelchair not fitting correctly. PTA-K reported that Resident 22's wheelchair had not been reassessed and also had stated the wheelchair was fairly new and was not sure if Medicaid would pay for a new wheelchair. PTA-K reported it was not clear if the wheelchair was causing Resident 22 pain and that the DOR (Director of Rehabilitation)-L would have to be the person to assess Resident 22 and see if the wheelchair was causing the pain. PTA-K reported that DOR-L had not completed another wheelchair assessment since Resident 22's chair was so new and no one had requested to have it re-evaluated. Interview on 03-06/18 at 12:06 p.m. with Resident 22 revealed the wheelchair had not been reassessed to see if this was causing the resident's back and hip pain. Interview on 03/06/18 at 12:23 p.m. with LPN (Licensed Practical Nurse)-D verified there were no orders to have Resident 22's wheelchair reassessed to determine if this was the root cause of the resident's back pain. Interview on 03/06/18 at 2:04 p.m. with the Administrator and Corporate Nursing Consultant verified that follow up had not been completed on the resident's wheelchair to see if this was the root cause of the resident's pain. |
2020-03-01 |