| 42 |
LEFA SERAN SNF |
295001 |
1ST AND A ST/ PO BOX 1510 |
HAWTHORNE |
NV |
89415 |
2017-10-12 |
309 |
E |
0 |
1 |
Z18S11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to assess and document pain levels for 6 of 10 sampled residents and to ensure a physician order [REDACTED].#1, #2, #4, #5, #6, #8). Findings include: Resident #5 Resident #5 was admitted on [DATE], with [DIAGNOSES REDACTED]. A physician order [REDACTED]. The Treatment Administration Record (TAR) for (MONTH) (YEAR) and (MONTH) (YEAR), indicated the resident's pain level had not been documented for the following dates: October Day Shift: On 10/08/17, 10/ , 10/03/17, 10/01/17. September Day Shift: On 09/30/17, 09/28/17, 09/26/17, 09/25/17, 09/24/17, 09/23/17, 09/19/17, 09/18/17, 09/15/17, 09/14/17, 09/12/17, 09/10/17, 09/08/17, 09/07/17, 09/05/17, 09/04/17, and 09/03/17. Night Shift: On 09/10/17 and 09/07/17. On 10/11/17 at 3:45 PM, the Director of Nursing (DON) confirmed the facility lacked documented evidence of pain monitoring for Resident #5. The DON acknowledged the physician's orders [REDACTED]. Resident #4 Resident #4 was admitted on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Resident #4's clinical record lacked documented evidence the resident's pain level was documented for the day shifts on 10/03/17, 10/06/17, 10/08/17, and 10/09/17, and for the night shift on 10/09/17. On 10/12/17 at 9:44 AM, the Director of Nursing (DON) confirmed Resident #4's clinical record lacked documentation of the resident's pain level on the above shifts and dates. Resident #8 Resident #8 was admitted on [DATE] and re-admitted on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Resident #8's clinical record lacked documented evidence the resident's pain level was documented for the day shifts on 10/03/17, 10/06/17, and 10/08/17. On 10/12/17 at 1:58 PM, the DON verbalized Resident #8's pain was to be evaluated and documented on both the day and night shifts. The DON confirmed Resident #8's clinical record lacked documentation of the resident's pain level on the above shifts and dates. The facility policy titled Documentation, Revised date, 09/17/12, revealed documentation into the electronic clinical record system was to be completed each shift. Resident #1 Resident #1 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #1's Medication Review Report listed resident orders, documented the resident was to have pain level evaluated on a scale of 0-10 with a start date of 10/24/14. Resident #1's Treatment Administration Records (TAR) for (MONTH) (YEAR) - (MONTH) (YEAR) lacked documented evidence a nurse monitored pain as indicated for the following months: 07/2017, 7 of 31 days on the day shifts and 4 of 31 days on the night shifts 08/2017, 9 of 31 days on the day shifts 09/2017, 19 of 30 days on the day shifts 10/2017, 3 of 11 days on the day shifts On 10/12/17 at 10:20 AM, a Registered Nurse (RN) explained Resident #1 always said yes to pain when asked about pain. The RN verbalized she looked at physical cues for pain for Resident #1 and entered a number from the pain scale. Resident #2 Resident #2 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #2's Medication Review Report listed resident orders, documented the resident was to have pain level evaluated on a scale of 0-10 every day and night shift with a start date of 07/13/17. Resident #2's clinical record lacked documented evidence a nurse monitored pain as indicated for the following months: 07/2017, 4 of 18 days on the day shifts 08/2017, 9 of 31 days on the shifts 09/2017, 19 of 30 days on the shifts 10/2017, 3 of 11 days on the shifts Resident #2's Medication Review Report documented the resident was to have the following medications related to pain: -Tylenol 325 milligram (mg), two tablets every four hours as needed for pain with a start date of 07/13/17. -[MEDICATION NAME]-[MEDICATION NAME] 5-325 mg, one tablet every four hours as needed for moderate pain 07/13/17. -[MEDICATION NAME] Patch 5%, apply for twelve hours to each postural shoulder topically one time a day for pain with a start date of 09/18/17. Resident #2's Medication Administration Record (MAR) for 07/2017-10/2017 documented Tylenol 325 mg, two tablets every four hours as needed for pain. On 10/12/17 at 10:44 AM, the Director of Nursing (DON) explained pain assessments for residents at the facility were the Treatment Administration Records (TAR) monitoring, effectiveness of a PRN (as needed) pain medication, the Minimum Data Set (MDS) pain level question, and an assessment sheet in the electronic medical record. The DON confirmed the assessment sheet in the electronic medical record had not been completed for Resident #1. On 10/12/17 at 10:20 AM, the RN verbalized Resident #1 and Resident #2 required monitoring for pain and was to be documented on the TAR. The RN explained sometimes the day shift got busy and was unable to complete the TAR. On 10/12/17 at 11:05 AM, the DON verbalized the RN was not to enter a pain scale number for a non-verbal resident and should have asked for a clarification order if the resident was non-verbal. The DON explained Resident #1 was verbal. The DON confirmed Resident #2's MAR and physician's orders [REDACTED]. The facility policy for Assessment and Documentation of Pain, effective 04/01/03, documented personnel assessing reports of pain shall request the patient to rate the pain on a scale of 1-10 or complete the non-verbal indicators on the assessment sheet. If a physician orders [REDACTED]. Resident #6 Resident #6 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #6's Treatment Administration Records (TAR) indicated the resident was to have pain assessed every shift using a pain level scale of 0-10. This order has been in effect since the Resident's previous admission on 12/01/11. The resident was non-verbal. 08/2017 lacked documented evidence a nurse monitored pain 8 of 31 day shifts and 1 of 31 night shifts. 09/2017 lacked documented evidence a nurse monitored pain 18 of 30 day shifts and 1 of 30 night shifts. 10/2017 lacked documented evidence a nurse monitored pain 4 of 11 day shifts and 1 of 11 night shifts. The DON confirmed the resident was non-verbal on 10/11/17 and the resident would grimace if experiencing pain, a pain scale would not have been an accurate tool to assess pain for a non-verbal resident. On 10/12/17 at 11:05 AM, the DON verbalized the RN was not to enter a pain scale number for a non-verbal resident and should ask for a clarification order if the resident is non-verbal. No other pain assessment documentation was available for this resident. The facility policy for Assessment and Documentation of Pain, effective 04/01/03, documented personnel assessing reports of pain shall request the patient to rate the pain on a scale of 1-10 or complete the non-verbal indicators on the assessment sheet. |
2020-09-01 |