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Based on interview and record review, the facility failed to ensure their Pain Reassessment, Medication Administration, and Pressure Injury Assessment, Prevention, Treatment & Management, policies and procedures (P&P) were implemented for six of 30 patients (Patients 2, 4, 6, 10, 22, and 29, when:

1. Patients 2, 4, 6, 22, and 29's pain levels were not reassessed within 60 minutes after administration of pain medications (Refer to A-0398);

2. For Patient 10, who was unable to manage pressure relief independently, was not turned and repositioned every two hours resulting in a deep tissue injury (Refer to A-0398); and

3. For Patient 22, pain medication refusal was not reported to the physician, nor was there documentation of subsequent attempts to administer the medication (Refer to A-0398).

These cumulative failures had the potential to compromise patient safety, result in inadequate pain management, and increase risk for pressure injuries.

Based on interview and record review, the facility failed to ensure their Pain Reassessment, Medication Administration, and Pressure Injury Assessment, Prevention, Treatment & Management, policies and procedures (P&P) were implemented for six of 30 patients (Patients 2, 4, 6, 10, 22, and 29, when:

1. Patients 2, 4, 6, 22, and 29's, pain was not reassessed within 60 minutes after administration of pain medication;

2. Patient 10, who was unable to manage pressure relief independently, was not turned and repositioned every two hours, resulting in a deep tissue injury (a serious bruise under the skin that occurs when pressure is on one part of the body too long like sitting or lying in the same position); and

3. Patient 22's medication refusal was neither documented nor reported to the doctor, and there was no evidence of a subsequent attempt to administer the medication.

These failures had the potential to compromise patient safety, resulting in poor pain management, increase risk of pressure injuries, and delays in medical care.

Findings:

1 a. A review of Patient 2's medical record was conducted on October 1, 2024, at 1:30 p.m., with the Stroke Program Coordinator (SPC).

A review of the facility's document titled, "History and Physical (H&P)," indicated, Patient 2 was admitted to the facility on September 24, 2024, for acute renal failure (kidneys stop working) and diarrhea.

A review of Patient 2's medication administration record (MAR) indicated, there was no documented evidence a pain reassessment (checking patient's pain if increased or decreased) was done on the following dates and times:

-On September 28, 2024, at 2:18 p.m., Morphine (MS, pain medication indicated for severe pain) 2 milligrams (mg, unit to measure how much medication to take) intravenous (IV, medicine or fluid given directly into a vein) was given for a pain level of eight out of 10 (pain level, describes severity of pain, zero meaning no pain and 10 meaning the worst pain possible);

-On September 29, 2024, at 5:18 a.m., MS 2 mg IV was given to Patient 2 for a pain level of 10 out of 10; and

-On September 30, 2024, at 2:18 p.m., MS 2 mg IV was given to Patient 2 for a pain level of eight out of 10.

An interview was conducted on October 1, 2024, with the SPC. The SPC stated the staff did not perform pain reassessments within 60 minutes after interventions on the above dates listed for Patient 2, which was not in accordance with the facility's policy.

1 b. A review of Patient 4's medical record was conducted on October 2, 2024, at 9:30 a.m., with the Cardiac Care Coordinator (CCC).

A review of the facility's document titled, "H&P," indicated, Patient 4 was admitted to the facility on September 24, 2024, for pancreatic mass (abnormal growth in the pancreas).

A review of Patient 4's MAR indicated on October 2, 2024, at 9:33 a.m., Dilaudid (pain medication, indicated for breakthrough severe pain) 1 mg IV was given to Patient 4 for a pain level of nine out of 10.

An interview was conducted on October 2, 2024, at 9:55 a.m., with the CCC. The CCC stated the staff did not perform a pain reassessment within 60 minutes after interventions for Patient 4, which was not in accordance with the facility's policy.

1 c. A review of Patient 6's medical record was conducted on October 2, 2024, at 10 a.m., with the Cardiac Care Coordinator (CCC).

A review of the facility's document titled, "H&P," indicated, Patient 6 was admitted on July 2, 2024, for acute cerebral vascular accident (CVA, blood flow to part of brain is blocked).

A review of Patient 6's MAR indicated there was no documented evidence pain reassessments was done on the following dates and times:

-On July 3, 2024, at 2:25 a.m., MS 2 mg IV was given to Patient 6 for a pain level of eight out of 10; and

-On July 5, 2024, at 6:25 a.m., MS 2 mg IV was given to Patient 6 for a pain level of eight out of 10.

An interview was conducted on October 3, 2024, at 10:30 a.m., with the CCC. The CCC stated the staff did not perform pain reassessments within 60 minutes after interventions for Patient 6, which was not in accordance with the facility's policy.

1 d. A review of Patient 22's medical record was conducted on October 2, 2024, at 9:00 a.m., with the Stroke Program Coordinator (SPC).

A review of the facility's document titled, "H&P," indicated, Patient 22 was admitted to the facility on August 13, 2024, for bilateral (affecting both legs) leg swelling and liver cirrhosis (liver disease).

A review of Patient 22's MAR indicated, there were no documented evidence pain reassessments were done on the following dates and times:

- On August 14, 2024, at 5:04 p.m., Ibuprofen (pain medication, indicated for mild pain) 400 mg was given with no documented pain level prior to administration;

- On August 14, 2024, at 9:16 p. m., Ibuprofen 400 mg was given with no documented pain level prior to administration;

- On August 18, 2024, at 11:28 a.m., Tylenol (pain medication, indicated for mild pain) 650 mg was given for a pain level of six out of 10;

- On August 18, 2024, at 2:27 p.m., Tylenol 325 mg was given for a pain level of seven out of 10;

- On August 18, 2024, at 4:36 p.m., Tylenol 650 mg was given for a pain level of four out of 10;

- On August 21, 2024, at 6:28 a.m., Tylenol-Hydrocodone (pain medication, indicate for severe pain) 325 mg-5 mg was given for a pain level of 10;

- On September 1, 2024, at 5:59 p.m., Tylenol 650 mg was given with no documented pain level prior to administration;

- On September 4, 2024, at 8:30 a.m., Tylenol 650 mg was given with no documented pain level prior to administration.;

- On September 6, 2024, at 8:32 a.m., Tylenol 650 mg was given with no documented pain level prior to administration; and

- On September 7, 2024, at 12:33 a.m. Tylenol 650 mg was given with no documented pain level prior to administration.

An interview was conducted on October 2, 2024, at 2:00 p.m., with the SPC. The SPC stated pain reassessments should be done 60 minutes after medication administration. The SC further stated pain levels should be assessed prior to pain medication administration and documented in the medical record.

1 e. A review of Patient 29's medical record was conducted on October 3, 2024, at 10:40 a.m., with the Stroke Program Coordinator (SPC).

A review of the facility's document titled, "History & Physical," indicated, Patient 29 was admitted to the facility on August 12, 2024, for sepsis (serious illness when the body has a strong reaction to an infection).

A review of Patient 29's MAR indicated there was no documented evidence pain reassessments were done on the following dates and times:

- On August 14, 2024, at 11:11 a.m., Norco (pain medication, indicated for severe pain) 325/10 mg tablet was administered for a pain level of nine out of 10;

- On August 14, 2024 at 6:30 p.m., MS 1 mg IV was administered for pain level of six out of 10.

An interview was conducted on October 3, 2024, at 11:00 a.m., with the SPC. The SPC stated the staff did not perform pain reassessments within 60 minutes after interventions for the dates listed above for Patient 29, which was not in accordance with the facility's policy.

A review of the facility's P&P titled, "Adult Pain Management," dated August 8, 2021, indicated, "...To assure the adequate assessment, reassessment and treatment of pain for patients throughout the continuum of care...Reassessment of pain post [after] intervention is documented within 60 minutes after intervention..."

2 a. A review of Patient 10's medical record was conducted on October 2, 2024, at 10:30 a.m., with the Cardiac Care Coordinator (CCC).

A review of the facility's document titled, "History and Physical," indicated, Patient 10 was admitted to the facility on April 24, 2023, for acute right MCA (middle cerebral [brain] artery [blood vessel that carries oxygen away from the heart]) stroke.

A review of the facility's document titled, "Nursing Admission Assessment," dated April 24, 2023, indicated Patient 10's Braden score was 12 (a scoring system to identify if a patient was at risk of developing pressure injury, with a score of 10-12 indicating high risk).

A review of Patient 10's repositioning schedule was conducted. There was no documented evidence Patient 10 was repositioned on the following dates and times:

- On May 14, 2023, from 10 p.m., until May 15, 2023, at 1:50 a.m. (3 hours and 50 minutes);

- On May 15, 2023, from 1:50 a.m., until 5 a.m. (3 hours and 10 minutes);

- On May 15, 2023, from 12 noon until 7:30 p.m. (7 hours and 30 minutes);

- On May 16, 2023, from 1 a.m., until 5:17 a.m. (4 hours and 17 minutes); and

- On May 20, 2023, from 4 p.m., until 8 p.m. (4 hours).

A review of the facility's document titled, "Wound Care Notes," dated April 27, 2023, indicated, "...Wound Care Nurse recommendations...Turn and reposition patient every two hours, off load heel and sacrum and nutritional support..."

A review of the facility document titled, "Wound Care Notes," dated May 15 2023, at 11:59 a.m., indicated, "...Turn and reposition patient every two hours..."

A review of the Wound Care Notes," dated May 18, 2023, at 2:01 p.m., indicated, "...sacral wound hospital acquired, deep tissue injury that had opened...wound started as a blister..."

On October 2, 2024, at 11:15 a.m., an interview was conducted with the CCC. The CCC stated, Patient 10 was not turned and repositioned every two hours on the above dates. The CCC stated the staff did not follow the wound care nurse's recommendations or the facility policy. The CCC further stated the wound could have been prevented if Patient 10 had been turned every 2 hours on all shifts.

A review of the facility's policy and procedure (P&P) titled, "Pressure Injury Assessment, Prevention, Treatment & Management," dated September 22, 2022, indicated, "...To establish a consistent, evidence based approach to pressure injury prevention and management...Repositioning...For patients who are bed-bound and do not interact with the environment, turn every 2 hours or more frequently as needed..."

3 a. A review of Patient 22's medical record was conducted on October 2, 2024, at 9:00 a.m., with the Stroke Program Coordinator (SPC).

A review of the facility document titled, "History and Physical," indicated, Patient 22 was admitted to the facility on August 13, 2024, for bilateral leg swelling and liver cirrhosis (liver disease).

A review of the Medication Administration Record (MAR) indicated, Lactulose (medication for Liver Cirrhosis) 22.5 ml (milliliters, unit of measure) was to be given orally every eight hours. Further review of the MAR indicated three doses of Lactulose that were not given because Patient 22 refused medications on the following dates and times:

- On August 21, 2024, at 11:00 p.m., Lactulose 22.5 ml was not given as ordered;

- On August 22, 2024, at 8:00 a.m., Lactulose 22.5 ml was not given as ordered; and

- On August 22, 2024, at 3:00 p.m., Lactulose 22.5 ml was not given as ordered.

An interview was conducted on October 2, 2024, at 9:00 a.m., with the SPC. The SPC stated if a medication was not given the nurse should document the reason and notify the physician. The SPC stated there was no documented evidence why Patient 22 refused the medication, which was not in accordance to facility's policy.

An interview was conducted on October 2, 2024, at 1:42 p.m., with Registered Nurse (RN) 1. RN 1 stated when the patients refuse medications, the policy is to check if the patient is alert and then educate the patient on why they are taking the medication. RN 1 stated Patient 22 refused the Lactulose because it made him go to the bathroom too much. RN 1 further stated she did not document education on importance of medication and she also did not notify the physician.

A review of the facility's P&P titled, "Medication Administration," dated September 22, 2022, indicated, "...If the patient still refuses a medication, the health care professional will document education and efforts and patient refusal, chart...If the patient refuses more than two (2) sequential doses of a scheduled medication...the physician shall be notified for evaluation and further orders...Pharmacy may be consulted for education and evaluation..."