| 51 |
DAMAS HOSPITAL SNF |
405023 |
2213 PONCE BY PASS |
PONCE |
PR |
717 |
2017-05-25 |
309 |
L |
1 |
1 |
NJQB11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on a standard/extended FOSS and complaint investigation PR 598 survey conducted on 5/22, 5/23, 5/24, and 5/25/17, seven records review (RR), and review of policies and procedures (P&P's), it was determined that the facility failed to provide the necessary care to assess and manage pain of residents who had more than one medical comdition to ensure that residents (R) reach their highest practicable well-being for 1 out of 7 sample selection residents (R #6). Findings include: 1. Resident #6 is a [AGE] years old male admitted on [DATE] with a [DIAGNOSES REDACTED]. The resident #6 was admitted for physical therapy, occupational therapy and wound care. The resident #6 was discharge home on 5/18/17 at 12:50 pm, having a length of stay of 51 days in the facility. The close record review was performed on 5/25/17 at 2:00 pm and the following was found: a. The Minimum Data Set (MDS) report of 4/4/17 on section G0110. Activities of Daily Living (ADL) Assistance on 5/25/17 at 3:12 pm provides evidence that the resident #6 is total dependent on bed mobility and that includes how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture. The resident #6 needs full staff performance every time in bed mobility, one personal physical assist. b. The Minimum Data Set (MDS) report of 4/4/17 on section J0100 Pain Management on 5/25/17 at 3:12 pm provides evidences that the resident #6 is received scheduled pain medication regiment, received PRN pain medication or was offered and declined, pain is suffered occasionally, the worst pain event during the last five days was 8/10 and severe. c. During review of the nursing notes of 4/6/17 was found incongruence between the pain documentation of the nursing staff and what the patient referred. The nursing note provides evidence that the patient did not had pain, however the patient referred that he had such pain that caused him vomiting episodes. d. During review of the nursing notes of 4/6/17 was found evidence that the nursing staff did not included in her note information related of the resident #6 clinical changes and needs. e. During the Change of position form of 4/6/17 provides evidence that the nurse change the patient position at 12:00 am, 2:00 am, 4:00 am, and 6:00 am. However the patient referred that the nursing staff did not perform any changes on position after 1:35 am thru 6:00 am. f. During review of the Facility Re-assessment of Pain form was found evidence that the nursing staff documented the pain scale on 4/6/17 at 12:00 am (0/10), 4/6/17 at 4:00 am (0/10), and 4/6/17 at 6:00 am (5/10). However the resident #6 referred that the nursing staff did not come to the room from 1:35 am thru 6:00 am and that he was suffering of pain during that time. g. During review of the Medication record was observed that the patient received [MEDICATION NAME] 5/325 mg 1 tab Oral (PO) every 3 hours when needed (PRN) for pain on 4/3/17 at 9:00 am and 9:50 pm, 4/4/17 at 10:00 am and 5:30 pm, 4/5/17 at 10:00 am and 5:00 pm. However from 4/5/17 at 5:00 pm thru 4/6/17 at 6:00 am (11 hours) the patient did not received medication for pain during eleven hours. The patient referred during interview that he had such pain that caused him vomiting episodes. h. During the medical order reviews was found evidence of a telephone order from the physician of [MEDICATION NAME] 5/325 mg 1 tab PO PRN every 3 hours for pain. The medication was administered on 4/6/17 at 6:00 am. i. During the interdisciplinary group notes was found evidence that RN employee #10 oriented the resident #6 about the importance of position changes every 2 hours and to avoid the pressure on the affected area. j. During review of the nursing care plans was found evidence that the Pain, Fall, and Pressure Ulcer care plans were open. 2. The Pain care plan establishes the following: a The use of therapeutic modalities for the pain management and pain control like: Positioning. b. Administer medication according to medical order for pain management. c. Pain note in clinical file must include: sounds, complaints, facial expressions, and movements. The resident #6 referred that from 1:35 am thru 6:00am he did not received change of position and pain medications. 3. The Fall care plan establishes the following: a. Provide rounds every two hours to three hours and / or more frequent in patients identified at risk. The resident #6 referred that the nursing staff did not come to the room from 1:35 am thru 6:00 am. 4. The Pressure Ulcer care plan establishes the following: a. Perform interventions aimed at preventing the development of area and pressure ulcers b. Promote and reposition every two hours c. Keep the skin dry, clean and lubricated d. Educate the resident and family about the treatment of [REDACTED]. 5. During the complaint investigation PR 598 of the resident #6 it was found the following: a. The resident #6 called the nursing station for help in bed mobility on 4/6/17 at 1:35 am. The Registered Nurse (RN) (Employee #11) went to the room and helped him; however she did it with a rude attitude towards him. b. The resident #6 referred that when the RN (Employee #11) went to room [ROOM NUMBER]A she stated: I will not come back until 4:00 am. c. The resident #6 referred that when the practical nurse (LPN) (Employee #12) went to room [ROOM NUMBER]A she stated: you only came to this facility for physical therapy and nothing more. d. The resident #6 called the nursing station on multiple occasions for help and assistance in bed mobility because he was in pain caused by the sacral ulcer and a previous surgery. The pain caused that the resident suffer from vomit episodes. The resident referred that the nursing staff did not return to the room anymore. e. The resident #6 referred that he made a telephone call to his wife at approximately 4:00 am and she arrived to the facility on [DATE] at 4:30 am. The report of the complaint provides evidence that the wife of the resident #6 found him without bed sheets, with pain, and dirty with vomit to which she had to clean without nursing assistance. 6. The facility failed to manage pain to residents who had more than one active medical condition (pressure sore, status [REDACTED]. |
2020-09-01 |