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Based on observation, interview and record review, the facility failed to provide adequate pain management prior to repositioning and wound care for one (#2) of three patients observed for pressure injury wound care, resulting in pain and a failure to achieve the Nursing Care Plan Goal for Pain Management for this patient. In addition, the facility failed to ensure that Nursing Care Plan interventions to prevent the spread of infection with a multi drug resistant organism to patient visitors were consistently followed for one (#2) of two patients reviewed for Contact (isolation) precautions, out of a total sample of 10, resulting in the potential for the spread of infections with a multi drug resistant microorganism to Patient #2's family members. Findings include:

On 7/17/19 at 1315, Patient #2's wound care and dressing change for her multiple Stage IV (full thickness skin loss exposing bone and/or underlying muscle) by Registered Nurse (RN) Staff M assisted by Charge Nurse Staff N was observed with the Chief Nursing Officer Staff A. A sign on the room door advised all persons to speak with the Nurse before entering the room. Personal Protective equipment (PPE -, required equipment = gown and disposable gloves) was available in a cabinet outside the room door. Patient #2 was sitting up in bed in no apparent distress. Patient #2 was smiling, relaxed and was pleasantly confused. Patient #2 was able to correctly state her name when asked. Patient #2 was able to state her date of birth after extensive cueing by Staff M. Patient #2's family member/responsible party was feeding Patient #2 and was not wearing a protective gown or gloves as required for Contact Precautions. Patient #2's seven year old great grandson was playing in the room and was not wearing any PPE.

On 7/17/19 at 1317 Patient #2's responsible party was asked if they were aware that Patient #1 was in Contact Precautions and that everyone should wear PPE in the room and perform hand sanitization before leaving the room. Patient #2's responsible party replied, "No. Nobody said anything to me. Why is she in Contact Precautions? Does she have MRSA (methacillin resistant Staphylococcus Aureus - a multi drug resistant microorganism) in her pressure sores again? She got MRSA in them last time she was here. I never would have brought my grandson here if I knew she was in Contact Isolation. He's nasty and can't keep his hands out of his mouth and nose."

On 7/17/19 at approximately 1318 Staff M was asked if she told Patient #1's Responsible Party that Contact Precautions were in place for Patient #2 and provided education to the Responsible Party regarding required protective gown and gloves while in the room and sanitizing hands when leaving the room. Staff M stated that she did not.

On 7/17/19 at approximately 1320 , Staff M and Staff N rolled Patient #1 over to her side to provide incontinence care for a bowel movement. Patient #2's bed linens and wound dressings were observed to be stained with areas of serosanguinous drainage. Patient #2 began to grimace, moan and call out, "Oh, Jesus help me, Oh Jehovah help", as soon as staff began to turn her. Patient #2 continued to moan and grimace each time she was moved and began to call out more loudly, "Oh help me Jesus, Oh God, Jehovah, Oh God, you're going to hurt me", and moaned and grimaced as Staff M began to clean her grapefruit sized Stage IV pressure injury and pack it with wet gauze. Patient #2 continued to moan and call out, "Oh no. That's hurting. Help me Jesus", as Staff M cleaned and packed her right hip 10.5 centimeter (cm) by 11.7 cm Stage IV pressure injury and her 6.5 cm by 11 cm Stage IV right ischium (hip bone) pressure injury. At this time Staff M was asked what Patient #2 had ordered (prescribed) to treat pain.

On 17/19 at 1330 Staff N opened Patient #2's medication administration record (MAR) on the bedside computer and reported that Patient #2 had an order for Percocet (oxycodone/acetaminophen) 5-325 one pill every six hours as needed (Q 6 PRN). Staff N stated that Patient #2 had received pain medication that morning. Review of Patient #2's MAR at this time with Staff N revealed Patient #2 received one PRN dose of Percocet 5/325at 0500 on 7/17/19 and nothing for pain since that time (8 hours and 45 minutes). At 1325 The Chief Nursing Officer Staff A told Staff N and Staff M that Patient #2 appeared to be in significant pain and the wound care should be stopped until after Patient #2 received a PRN Percocet.

On 7/18/19 at approximately 1200, the Infection Preventionist/ Unit Epidemiologist Staff P was interviewed regarding Patient #2 and stated that he wrote an order for Patient #2 to be placed in Contact Precautions on 7/15/19 at 1135 because, "This patient had a tissue culture that grew a Multi-Drug Resistant Organism (MDRO) on her previous admission and has not had any repeat cultures of the wounds done since. The Nursing care plan contains instructions on patient and family education regarding infection. This should be documented daily. If the nurse sees visitors in the room without PPE she should educate them about the risks of infection and instruct them to put on a gown and gloves and be careful about handsanitizing or washing when they exit. If the guests are noncompliant, the nurse should notify the charge nurse or unit manager, and if necessary they should notify the Epidemiology department so that we can get involved."

On 7/18/19 at 0900 Patient 2's clinical record was reviewed with Staff D and revealed the following:

Patient #2 was an 86 year old female who was admitted to the facility five times in 2019. diagnoses included End Stage Dementia, Metabolic Encephalopathy, Chronic Kidney Disease, History of Cerebra-vascular Accident (stroke) with spastic hemiplegia (half of body paralyzed) Anemia, Gastrointestinal Bleeding, Urinary Tract Infection, Malnutrition, Osteomyelitis (infection of the bone and muscle), Methacillin Resistant Staphylococcus Bacteremia (MRSA blood infection), and multiple infected Stage IV Pressure Injuries. Patient #1's most recent admission was on 7/13/19 for a diagnosis of Pressure Injuries.

An Admission Physician Assessment from her previous admission from 5/16/19 through 6/11/19 noted the following "Sent in from (Wound Clinic) for management of wounds. Per Doctor was sent to hospital due to (d/t) severity and amount of ulcers. She has 10 large open ulcers with necrotic tissues and malodorous drainage." Patient #2 underwent surgical debridement (removal of dead tissue) of pressure injuries during this admission and review of laboratory results from bone and tissue removed during this surgery dated 6/4/19 revealed Patient #2's bone and muscle tissue from the pressure injury wounds was infected with a multi-drug resistant microorganism, a Carbapenem Resistant Enterococcus (CRE).

A Plastic Surgery note dated 5/17/19 at 0837 noted, "(patient ) states that sometimes her wounds are painful. Wounds are either Stage IV or Unstageable (unable to determine depth of wound due to covering of dead tissue)."

Review of pain assessments for Patient #2 from 7/13/19 through 7/17/19 revealed pain was assessed every shift for Patient #2 and most pain assessments documented that Patient #2 had zero pain (none), but there was documentation by some nurses that Patient #2 had pain with repositioning and with wound care. There was no documentation of whether Patient #2 tolerated dressing changes on her multiple Stage Pressure Injury wounds without significant pain.

A non verbal pain assessment done on 7/17/19 at 0939 (four hours before the observed wound care on 7/17/19) noted that Patient #2's. pain was assessed as "Zero (none)". A pre-medication pain assessment on 7/17/19 at 1439 assessed Patient #2's pain at that time as 2 out of 10 (slight pain) on the facility's non verbal pain rating scale.The date and time of this "pre-medication" pain assessment corresponded to the date and time Patient #1's wound care was interrupted in order to medicate for pain before resuming wound care due to observed moaning, grimacing and yelling out that it hurt and calling on Jesus and Jehovah for help.

A Patient/family education form documented that Staff Nurse M documented that she educated Patient #1's self/family on contact precautions on 7/17/19 at 0901. It was not documented who Staff M educated on contact precautions.

A Nursing Care Plan for Pain for Patient #2 was updated each shift and documented that Patient #2 was progressing towards the goal of zero pain.

A Nursing Care Plan for Infection noted the following patient/family education goals on 7/17/19: "Isolation Precautions: educated patient/family/caregiver on current isolation precautions including protective equipment and need for diligent handwashing. discourage visitors that show signs or symptoms of illness or visitation from young children.

Review of the provided policy on Pain, entitled "pain management in the adult and pediatric population, dated 1/28/19 failed to provide instructions to nursing to evaluate pain during procedures. The following instructions regarding pain assessment were noted, "For patients experiencing pain:
1. Pain is assessed with each new episode of pain and minimally every 4 hours.
2. If patient is sleeping: document sleeping and use an appropriate pain scale.
a. If the patient is not experiencing pain, pain is to be assessed with each set of routine vital signs.
3. Reassessment of pain is performed for each pharmacological and non-pharmacological intervention. A Pain Algorithm is located at the end of this policy.
4. The RN will assess effectiveness of pharmacological and non-pharmacological within one hour of providing the intervention"

Review of the facility policy entitled, "Isolation Practices, revised 5/2019 revealed the following staff instructions, "Educate all guests for the need to adhere to precautions prior to entering patient room", and, "Patients and guests are educated regarding isolation to ensure compliance with posted precautions."