**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure one (#1) of three residents reviewed for accidents out of 15 sample residents received adequate supervision and services to prevent an accident. Resident #1 was admitted to the facility on [DATE] with a traumatic subdural hemorrhage with loss of consciousness (intracranial bleeding between the brain and the skull), muscle weakness, aphasia (loss of the power of speech), hemiplegia (paralysis affecting one side of the body), Parkinson's disease (a condition that affects muscle control and movement), acute pain due to trauma and a history of falling. Resident #1 was status post [NAME] holes (small holes that a neurosurgeon makes in the skull to help relieve pressure on the brain when fluid, such as blood, builds up and compresses brain tissue) of subdural hematoma with surgical incision on the left side of his head with staples in place. On 4/15/24, certified nurse aide (CNA) #1 and CNA #2 transferred Resident #1 via the hoyer lift (mechanical lift). During the transfer, Resident #1 fell from the lift to the floor, striking his head. Resident #1 began vomiting after the fall and was immediately transferred to the hospital where he was diagnosed with a large posterior scalp hematoma (bleeding under the skin) and left ankle trauma with pain and mild soft tissue swelling. The facility failed to identify the root cause of Resident #1's fall, conduct staff re-education to prevent future falls, review transfer training techniques, or review the use of the hoyer lift procedures with CNA #1 and CNA #2, who were involved with the fall. Due to the facility's failure to transfer a dependent resident safely, Resident #1 sustained a new head injury and required hospitalization for three days. Resident #1 was discharged from the hospital to his home on hospice care due to the families concern for the resident's safety at the facility. Findings include: I. Facility policy and procedure The Mechanical Lifts policy and procedure, revised 2/1/23, was provided by the nursing home administrator (NHA) on 7/31/24 at 10:22 a.m. It read in pertinent part, (Facility name) utilizes mechanical lifts when appropriate to ensure safe patient handling during transfers and employee safety when providing patient care. Direct care staff will receive training upon hire and as needed for proper preparation of the patient, equipment, and environment during utilization of mechanical lifts. II. Mechanical lift manual The user manual for the Span model: F500P full body patient lift was provided by the NHA on 7/31/24 at 10:35 a.m. It read in pertinent part, Special care must be taken with users/patients who cannot themselves provide assistance while being lifted (patients who are comatose, spastic, agitated, or otherwise severely handicapped). The patient lift should be used solely for transferring a user/patient from one utility (beds, chairs, toilets) to another. The patient lift should not be used for transporting or moving any patient from one location to another location. During lifting or lowering, whenever possible, always keep the base of the lift in the widest position. The base of the lift should be closed before moving the lift. Do not roll casters over any object while the user/patient is in the sling. Do not lock casters during lifting. While being lifted in a sling, always keep the user/patient centered over the base and facing the caregiver operating the lifter. Never leave the user/patient unattended during lifting. III. Resident # 1 A. Resident status Resident #1, age [AGE], was admitted on [DATE] and discharged to the hospital on 4/15/24. According to the April 2024 computerized physician orders (CPO), diagnoses included traumatic subdural hemorrhage with loss of consciousness, muscle weakness, aphasia, hemiplegia Parkinson's disease, acute pain due to trauma and history of falling. The 4/15/24 minimum data set (MDS) assessment revealed the resident was unable to complete a brief interview for mental status (BIMS). The staff assessment for mental status was completed and revealed the resident had short and long-term memory problems and had severely impaired cognitive skills for daily decision making. He was dependent on staff for transfers, and required substantial/maximal assistance with bed mobility. The MDS assessment indicated the resident had one fall since admission and documented there was no injury. -However, the resident sustained a head injury with a hematoma, per the hospital records. B. Facility investigation of Resident #1's fall on 4/15/24 The fall investigation was provided by the director of nursing (DON) on 7/30/24 at 5:29 p.m. The 4/16/24 post fall investigation revealed the following in pertinent part: On 4/15/24 at 6:30 p.m. licensed practical nurse (LPN) #1 heard a loud bang and ran into the resident's room. Resident #1 was on the floor. CNA #1 and CNA #2 were using the hoyer lift to transfer the resident when Resident #1 slipped through the middle of the sling. Resident #1 hit the back of his head. The resident's vital signs were within normal limits.The physician and the resident's daughter were notified of the fall. The resident was evaluated by registered nurse (RN) #1 and she made the decision to send the resident to the emergency department (ED) as he had hit his head. The resident's vital signs were stable when the resident left the facility with emergency medical services via stretcher to the hospital ED. An undated statement was obtained from CNA #1. CNA #1 said she was sitting at the computer charting and giving a report to the next oncoming shift. She had asked CNA #2 if she would like her to help lay Resident #1 down and she replied sure. CNA #1 said the hoyer lift sling appeared to be properly in place. CNA #1 said she hooked the resident's sling up to the hoyer lift and began to lift him to the bed. She said Resident #1 suddenly began to slip out of the sling and onto the floor. An undated statement was obtained from CNA #2. CNA #2 said she worked on the night shift at (facility name). CNA #2 said she started her shift at 6:00 p.m. on 4/15/24. CNA #2 said after report was given from the day shift, one of the day shift CNAs offered to help get Resident #1 into bed before she left for the day. CNA #2 said they went to Resident #1's room and he was sitting in his wheelchair by the window side and was leaning towards his right side. CNA #2 said they adjusted Resident #1 the best they could. CNA #2 said they tucked in the hoyer lift sling and criss-crossed the sling between his legs and moved the wheelchair closer to the hoyer lift machine. CNA #2 said they then lowered the hoyer lift machine down to wheelchair level and proceeded to hook up the sling to the machine. CNA #2 said they used the first hook on all six hookups (three on left, three on right). CNA #2 said she had control of the hoyer lift and the other CNA (CNA #1) was guiding Resident #1 towards the bed. CNA #2 said the wheelchair was removed once he was high enough, then she proceeded to move towards the bed. CNA #2 said they were in position moving towards the bed when Resident #1 slipped out of the sling through the bottom. CNA #2 said Resident #1's bottom went through the sling and he landed on his bottom, and then fell backwards and hit his head. CNA #2 said at that point she was in a state of shock. CNA #2 said she had been doing that job for more than 10 years and that had never happened. CNA #2 said they went to Resident #1 and he was still awake, aware and trying to speak. CNA #2 said the nurse rushed in and called 911. CNA #2 said she stayed with Resident #1 until the ambulance and fire department came to help him off the floor. She said Resident #1 was then sent out to the hospital for further evaluation. An undated statement from the DON said CNA #1 and CNA #2 had both been through skills check-offs to include mechanical lifts, and both followed facility protocol for hoyer lift use. The statement said this had been an unfortunate, isolated event. The resident was evaluated at the hospital and the head computed tomography (CT) scan did not show any new bleeds. -However, according to the emergency progress note Resident #1 sustained a large posterior scalp hematoma (see record review below). C. Record review The baseline (admission) care plan, dated 4/13/24, revealed the resident required two person assistance with transfers, bathing, grooming, locomotion and toileting. The resident was at risk for falls related to impaired mobility secondary to weakness and debility and related to current drug regimen.The resident had acute and chronic pain. The 4/13/24 admission skin assessment revealed an actual surgical wound with dressing changes per physician orders. A review of the April 2024 CPO revealed a physician's order was set up to follow up with a neurological surgeon to remove the staples from the resident in five days, ordered on 4/14/24. The 4/16/24 nursing progress note, documented at 1:49 a.m., revealed the nurse heard a loud bang and the nurse ran into Resident #1's room. The resident was on the floor. The CNAs were using the hoyer lift and the resident slipped through the middle of the sling. The resident hit the back of his head. RN #1 came and evaluated the resident. The 4/16/24 change in condition note, documented at 2:42 a.m., revealed the resident's vital signs were within normal limits. The resident was vomiting after the fall. The note documented the physician and family were notified of the fall at 6:30 p.m. on 4/15/24. The 4/16/24 bed hold progress note, documented at 8:18 a.m., revealed the DON spoke with the resident's spouse who stated the resident would not be returning to the facility. The post fall evaluation, completed by the DON on 4/16/24, revealed the resident sustained a witnessed fall on 4/15/24. The resident hit his head and was transferred to the hospital. Neurological checks were initiated per facility protocol. A skin evaluation was not completed. The resident did not have pain from the fall and did not receive pain medication. The resident fell during a transfer in the resident's room with a hoyer lift and sling. The assessment documented the probable cause of the fall was the resident's buttocks slid through the sling onto the floor and the staff expressed that it was properly placed and the appropriate size sling was used. The IDT (interdisciplinary team) discussed the resident's fall. The resident was on the fall program with his bed in a locked and low position, received assistance from two persons at all times for hoyer lift transfers and to assure the sling fit correctly. The evaluation documented the care plan was revised on 4/16/24. It documented the physician and family were notified on 4/15/24. The 4/15/24 hospital progress note documented a [AGE] year old male with a history of Parkinson's disease and recent subdural hemorrhage status post [NAME] holes brought in to the emergency department from a rehabilitation facility after he was accidentally dropped out of a hoyer lift and hit his head once again. He was not on an anticoagulant and was nonverbal at baseline. He was noted to have a large posterior scalp hematoma that was new since prior exam. A review of the resident revealed he had pain to his left ankle with mild soft tissue swelling. X-rays were obtained and were negative. The hospital progress note documented the plan was for the resident to return to the rehabilitation facility, however the patient's wife had serious concerns about the safety of this facility and did not wish him to go back there. The note documented the resident's spouse was going to contact hospice and palliative care services tomorrow morning as her desire was to take him home on hospice care. The resident was discharged home on hospice from the hospital on 4/17/24. -Following Resident #1's fall on 4/15/24 from the hoyer lift, the facility failed to identify the root cause of Resident #1's fall, conduct staff re-education to prevent future falls, review transfer training techniques, or review use of the hoyer lift procedures with CNA #1 and CNA #2, who were involved with the fall. D. Staff interviews The DON was interviewed on 7/30/24 at 5:05 p.m. The DON said Resident #1 sustained a fall on 4/15/24 at 6:30 p.m. The DON said CNA #1 and CNA #2 witnessed the fall. She said CNA #1 and CNA #2 alerted LPN #2 after the fall. The DON said CNA #1 and CNA #2 were transferring Resident #1, via a hoyer lift, from his wheelchair to the bed and had lifted the resident up in the sling and out of the wheelchair and began to lift him to the bed and that was when Resident #1 fell. The DON said she felt it was a freak accident. The DON said the hoyer lift sling was placed correctly because staff had expressed that it was properly placed and the appropriate size. She said when the CNAs started moving Resident #1 toward the bed, he slipped through the sling. The DON said since Resident #1's admission he had required two person assistance with the hoyer lift. The DON said the comprehensive care plan was still being developed on the day the resident sustained the fall. She said the resident's care plan was not updated after the fall because the resident did not return to the facility. The DON said there was a communication board in the resident's room to let the caregivers know what assistance level the resident required. The DON said no further re-education training was provided to CNA #1 and CNA #2 after the fall because they were both very competent with transfers and she did not know what further instruction or information she could have told them on how they could have corrected the situation. The DON reiterated that she had never seen this type of accident before so there had not been specific training or corrective action given to the direct care staff after the fall. The DON said CNA #1 and CNA #2 had had training on the hoyer lift in February 2024 and had completed the skills competency checklist. The DON said the facility did not do any other training for all the staff after the fall on 4/15/24 because she did not think it was needed as they had just completed the annual skills checklist and there was nothing identified in the fall incident that could have improved the situation. CNA #2 was interviewed on 7/30/24 at 5:40 p.m. CNA #2 said Resident #1 fell on 4/15/24 when she had just come on shift. She said Resident #1 was in his wheelchair and CNA #1 had offered to help put him into bed. CNA #2 said it was dinner time and sometimes it got busy, so she was glad for the help. CNA #2 said the hoyer lift sling was under Resident #1 and the moment she moved the hoyer lift away from the wheelchair, the resident fell and hit his head on the floor. CNA #2 said she screamed and could not believe what happened. CNA #2 said she ran and got the nurse and the resident was sent to the hospital. CNA #2 said she could not pinpoint what went wrong with the transfer since the sling was already under him. CNA #1 was interviewed on 7/30/24 at 5:44 p.m. CNA #1 said she and CNA #2 went in to transfer Resident #1 on 4/15/24 via a hoyer lift. She said he fell out of the sling during the transfer. CNA #1 said Resident #1 was in his wheelchair and she and CNA #2 went to hook the hoyer lift sling up and put him to bed for the evening. CNA #1 said she hooked up the sling and he slipped out of the sling. CNA #1 said she and CNA #2 had put the hoyer lift sling underneath the resident. CNA #1 said she remembered that because she had been working with Resident #1 all day on the day shift. CNA #1 said Resident #1 had just finished eating his dinner. CNA #1 said when Resident #1 was lifted up with the hoyer lift, they were turning the hoyer lift to go to the bed and that was when Resident #1 slid out of the sling and hit the floor. CNA #1 said she was completely shocked and did not know what could have gone wrong. CNA #1 said she was trying to be extra careful with the hoyer lift transfers she was now doing but said she did not receive any new training after the resident's fall. LPN #2 was interviewed on 7/30/24 at 5:55 p.m. LPN #2 said when she entered Resident #1's room on 4/15/24, he was on his back on the floor. She said the resident was conscious. LPN #2 said she checked his vital signs and went to get RN #1. LPN #2 said Resident #1 started vomiting when the emergency medical technicians (EMT) arrived. RN #1 was interviewed on 7/30/24 at 6:00 p.m. RN #1 said another RN, who had since retired, came in to assess Resident #1. RN #1 said the nurse on the floor would typically complete a fall progress note. RN #1 said a progress note was not documented by the RN in the resident's EMR. RN #1 said she decided not to move the resident until the EMT's arrived. RN #1 said she came in later to check on the situation, the resident was still on the floor and the EMTs had arrived. RN #1 said she heard the CNAs say they had hooked the hoyer lift up and they were not sure what had happened or how he fell. She said the CNAs did not say the hooks fell off but the resident fell out of the sling. The DON was interviewed again on 7/30/24 at 6:13 p.m. The DON said she had put an education book about the different types of hoyer lift slings to use, how to know which size to use as a guide and placed them at the CNAs desk stations. The DON said she was not sure if any of the CNAs had looked at it or read it. The DON said the facility had not had any further incidents of hoyer lift falls, but said she had not done any official education with staff following the fall. E. Facility follow-up On 7/30/24 at 6:04 p.m. the DON provided documentation that CNA #1 had completed a skills competency checklist on 2/13/24 and CNA #2 had completed skills competency checklist on 2/17/24. The competency nurse aide skill checklist included 53 personal care skills, including hoyer use, with a date passed by demonstration and a signature. -However, the facility did not have CNA #1 and CNA #2 complete a new skills competency checklist following Resident #1's fall from the hoyer lift on 4/15/24. On 7/31/24 at 10:30 a.m. the NHA provided documentation that the facility had conducted weekly ongoing maintenance and hoyer lift inspections from January 2024 to present. On 7/31/24 at 1:09 p.m. the DON provided documentation of an audit that was performed by therapy on 7/31/24 (during the survey) to ensure residents who required hoyer lifts had the appropriate sling sizes and types and felt safe with them. The audit included five residents who were currently transferred by nursing staff using the hoyer lifts. On 8/2/24 at 9:45 a.m. the NHA sent an email which revealed in pertinent part, the NHA further reviewed the case (of the hoyer lift fall with Resident #1) with the facility medical director and the DON. The NHA said the chart reflected that when Resident #1 was returned to acute care post-fall, no significant changes from the prior studies were identified (attached were the before and after CT/neurology consult notes). The NHA said, specifically, Resident #1 had a previous history of brain injury/bleeds and that the staples identified in Resident #1's head were present upon admission to the facility. The NHA said no additional injuries or signs and symptoms of pain were noted by staff as a result of the fall. The in-services, audits sheets began and he would provide (see below). -However the hospital notes revealed after the facility fall Resident #1 sustained a new large posterior scalp hematoma (not subdural), and a new left ankle trauma with pain and mild soft tissue swelling (see record review above). In addition Resident #1 exhibited vomiting after the fall. On 8/2/24 at 2:21 p.m. the DON provided a signature page for the hoyer lift in-service. The hoyer lift in-service was dated 7/31/24 (during the survey). -However, the document revealed CNA #1 had the in-service emailed to her and CNA #2 did not participate in the in-service. -Additionally, the facility only provided the signature page, not the curriculum for the hoyer lift in-service.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews the facility failed to ensure a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and and does not develop pressure ulcers unless the individual's clinical condition demonstrates that the were unavoidable for one (#24) of four residents out of 40 sample residents reviewed for pressure ulcers. Resident #24 was admitted to the facility on [DATE] with a diagnosis of cerebral infarction (stroke), abnormal posture and muscle weakness. Resident #24 skin was assessed at admission on [DATE] as not having any pressure areas identified. The facility identified the resident at low risk for developing pressure ulcers, however per the 12/17/21 minimum data assessment, he was identified at risk for developing pressure ulcers. The facility failed to have preventative interventions in place to ensure Resident #24's feet were offloaded, failed to provide showers as preferred (cross-reference F561) and failed to complete all ordered weekly skin and foot assessments. Due to the facility's failures, the resident developed an avoidable, facility acquired unstageable pressure ulcer to his left heel, which was discovered by the resident's wife on 1/10/21. Furthermore, the resident indicated the pressure ulcer caused the resident pain and discomfort. Findings include I. Professional reference A. The NPUAP Pressure Injury Stages | The National Pressure Ulcer Advisory Panel - NPUAP. The National Pressure Ulcer Advisory Panel NPUAP. Web. (2/4/18) Accessed 1/27/22. http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages reads: A pressure injury is localized damage to the skin and/or underlying soft tissue, usually over a bony prominence as a result of pressure, or pressure in combination with shear. The updated staging system includes the following definitions: -Stage 1 Pressure Injury: Intact skin with a localized area of non-blanchable erythema. -Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. -Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. -Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. -Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar was removed, a Stage 3 or Stage 4 pressure injury will be revealed. B. According to the National Pressure Ulcer Advisory Panel (NPUAP), Prevention and Treatment of Pressure Ulcers, Quick Reference Guide. [NAME] Haesler (Ed.). Cambridge Media: [NAME] Park, Western Australia 2/14/18, accessed 1/27/22: Steps to prevent the worsening of existing pressure injuries and to promote healing include: Avoiding positioning that places pressure on the pressure injury, assessment and documentation of the pressure injury when discovered and reassessment and documentation at least weekly. Assessment should include location, category/stage, size, tissue types, color, periwound (the skin around the wound) condition, wound edges, and evidence of undermining or tunneling, exudate, and odor. II. Facility policy The Pressure Ulcer policy, revised 2/8/21, provided by the director of nursing (DON) on 1/24/22 at 2:00 p.m., read in pertinent part: The facility will provide the necessary requirements to ensure that a patient receives the treatment and care in accordance with professional standards of practice. -Upon admission, the nursing staff will complete a full skin evaluation and examine for any ulcerations or alterations in skin. -The physician will assist the staff with reviewing current orders when wounds are not healing as anticipated or new wounds develop despite existing interventions. III. Resident status Resident #24, age [AGE], was admitted on [DATE]. According to the January 2022 computerized physician orders (CPO) diagnoses included cerebral infarction (stroke), abnormal posture, muscle weakness and metabolic encephalopathy (chemical imbalance affecting the brain that can lead to personality changes). The 12/17/21 minimum data set (MDS) assessment revealed Resident #24 had severe cognitive impairment with a brief interview for mental status (BIMS) score of six out of 15. (However, according to the nursing note 1/1/22 he was alert and oriented to person, place and time.) He did not have mood or behavior symptoms and was not resistant to care. He required extensive assistance of two staff members for bed mobility, transfers, dressing and toilet use. He required extensive assistance of one staff member for personal hygiene. Bathing had not occurred. He was not steady and only able to stabilize with staff assistance when moving from seated to standing, moving on and off the toilet and with surface to surface transfers. He had impairment on one side of upper and lower extremities. He used a wheelchair for mobility. He did not have any pressure ulcers upon admission but was at risk for developing a pressure ulcer. The treatments indicated were pressure relieving devices in his chair and bed, turning and repositioning, however application of dressing to feet was not indicated. IV. Resident/wife interview and observations Resident #24's wife was interviewed on 1/12/22 at 1:57 p.m. She said the staff were now treating a pressure ulcer on his left heel that she brought to their attention a couple days ago. She said she was applying lotion to his feet when she felt something hard on his heel and notified the nurse, who then notified the wound care nurse. She said he did not have any pressure ulcers when he was admitted to the facility. She said, I have no doubt they did not know it was there because he had not received a bath or shower for the last month until I mentioned that to them as well and no one had been assessing his skin routinely. Resident #24 was interviewed and an observation of his left heel was done on 1/24/22 at 1:39 p.m. He was lying on his back in bed on a standard mattress, not an air mattress. He was wearing non-skid socks and his feet were not elevated off the mattress. The heels up pad which would have elevated his feet off the mattress was propped against the wall across from the foot of the bed. He said he did not have the pressure sore to his heel when he was admitted to the facility. He said the nursing staff had not completed full skin assessments on a weekly basis since his admission. He said the pressure sore on his left heel was painful at times and felt as if it was swollen. He said he had not refused to be turned, repositioned or have his heels elevated off the mattress. He said they left a soft boot (pressure relieving device) for him to wear on his foot but it was not on his foot, it was in a chair under a pillow. Resident #24's son was at the bedside and removed the sock from his left foot. The pressure ulcer was covered in a thick black skin and the surrounding skin had a rim of dark brownish skin as well. There was no bandage on the area and no drainage was observed. -At 5:11 p.m., Resident #24 was seen seated in his wheelchair being transported to the main dining room on the first floor. He did not have the pressure relieving soft boot on his left foot. He was wearing non-skid socks and his feet were resting directly on the foot pedals of the wheelchair without any protection/cushion. On 1/25/22 at 10:00 a.m. Resident #24 was again observed lying in his bed. He was not wearing the soft boot to his left foot nor were his feet elevated (floated) off the bed. -At 2:00 p.m. Resident #24 was seen in his room seated in his wheelchair interacting with a therapy staff member. He was wearing non-skid socks and his feet were resting on the foot pedals of the wheelchair. He was not wearing the soft boot on his left foot. V. Record review Review of the care plan, initiated 12/11/21 and 12/12/21, revealed Resident #24 required assistance with activities of daily living (ADLs) related to self care deficits and decreased functional mobility secondary to cerebral infarction and metabolic encephalopathy. He had actual/potential decline in his ability to perform ADLs. He had a potential for skin breakdown related to impaired mobility secondary to weakness and debility, decreased functional mobility, cerebral infarction and cognition deficits. Interventions included: to reposition patient throughout shifts as needed and see CNA (certified nurse aide) tasks and documentation for ADLs. Provide assistance as needed with grooming, bathing, and personal hygiene and per patient's preferences. Braden scale every week per protocol, and skin evaluation as ordered and as needed. Monitor/reminding/assist to turn/reposition frequently, as needed or requested. Pressure-relieving mattress per facility protocol and as ordered. Skin treatment per physician order. Review of the December 2021 CPO revealed an order dated 12/11/21 for skin prep (skin protectant) to bilateral heels every other day (QOD) at bedtime and orders dated 12/17/21 for weekly pain assessments, weekly pressure sore risk assessments and weekly skin and foot assessments. Review of the weekly pain assessments revealed the following: The 12/17/21 assessment indicated he was unable to answer but staff indicated he had pain when moving. The 12/31/21 assessment indicated he had occasional pain rated at 5 out of 10 (with 10 being the worst pain the scale). The 1/8/22 assessment indicated he had frequent pain rated at 4 out of 10. -Pain assessments were not completed on 12/24/21 or 1/14/22. Review of the Braden Scale for Predicting Pressure Sore Risk assessments completed on 12/31/21, 1/7/22 and 1/21/22 indicated Resident #24 was at low risk for developing a pressure sore with scores of 17, 18 and 17 respectively out of 23 with low numbers indicating higher risk. -The nursing staff had orders to assess the resident more frequently and should have completed four pressure sore risk assessments prior to the discovery of the unstageable ulcer on his left heel. Braden scale assessments were not completed on 12/17/21, 12/24/21 or 1/14/22. In addition, the 12/17/21 MDS assessment (see above) indicated the resident was at risk for developing a pressure ulcer. Review of the admission assessment and weekly skin assessments revealed the following documentation: The 12/12/21 nursing admission assessment, documented by registered nurse (RN) #5, indicated Resident #24 was oriented only to himself, he was bedfast, he was very limited in his ability to change or control body position and no pressure ulcers were documented. The 12/31/21 skin evaluation documented no pressure areas. The 1/7/22 skin evaluation documented no pressure areas. -Weekly skin assessments were not completed on 12/17/21, 12/24/21 or 1/14/22 and 1/21/22. The nursing staff should have completed five weekly skin assessments prior to the discovery of the unstageable left heel ulcer. Review of the daily skilled nursing notes, documented by RN #6 on 1/8/22 at 4:55 p.m. and on 1/9/22 at 5:11 p.m., one and two days prior to discovery of the pressure ulcer, revealed no documentation of an issue with Resident #24's heel. The 1/10/22 Skin/Wound Note-Late Entry, documented by licensed practical nurse (LPN) #3 at 6:13 p.m. read in part: This nurse notified of dark area to patients left heel. Immediately came to room and evaluated with charge RN, wife at bedside. Patient has foam wedge under his legs at this time. Dark, softly hardened tissue noted to site, soft perimeter of area noted as well. Patient does not complain of pain at this time. Using clean technique, area was cleansed, dried well, betadine applied. Physician notified of new incident; no signs or symptoms of infection noted. Educated patient and wife related to benefits of offloading boney areas. Have spoke to patient recently and at times he is resistive to repositioning, prefers supine positioning. Assistant director of nursing (ADON) and charge RN updated. Will continue to monitor. Wound physician (WP) notified of new skin concern; he will evaluate 1/12. Orders to float heels while in bed and interventions in place. -The orders to float heels when in bed and for the heels up pad were not added to the chart or the CNA task list until after the discovery of the heel ulcer on 1/10/22. The order, If patient refuses to use heels up positioning pad in bed, place elevating heel offloading bootie as patient will tolerate to left foot was not added to his chart until 1/20/22, which was 10 days after the heel ulcer was identified. There were no measurements of the wound identified on the skin/wound note. The 1/12/22 Skin/Wound note documented by LPN #3, at 7:25 a.m., read in part: Wound care evaluation today with the wound care team and WP related to the patients skin concerns to left heel. WP documentation to follow in chart. Wounds are progressing as expected, not worsening. Eschar (dead tissue) hardened, perimeter less pink, still no pain to area. Using clean technique, wound care was done on patient as they were lying in bed. Treatments were then done per recommendation of WP. Patient did tolerate the wound care well and was then repositioned after to comfort with heels up pad in bed. Treatment orders are now up to date in chart as well as care plan. We discussed with patient the benefits of wound care and also the importance of regular skin treatment regimen. We educated related to the importance of protein and good caloric value needed to help their skin heal. Patient voiced no concerns at this time; wife is aware and updated. Attending physician, nursing and dietitian have been updated - all satisfied at this time with their plan of care. The 1/12/22 Wound Care evaluation, documented by the WP read: Date of onset 1/10/22, left heel pressure is an unstageable pressure injury obscured full-thickness skin and tissue loss pressure ulcer and has received a status of not healed. Initial wound encounter measurements are 3 cm length x 3.1 cm width with no measurable depth, with an area of 9.3 square centimeters (sq cm). The patient reports a wound pain of level zero out of 10. Wound bed has 100% eschar. The periwound skin texture is normal. The periwound skin moisture is normal. The periwound skin color is normal. Wound Orders: Cleanse wound with normal saline, apply betadine to area twice daily (BID). Preventive Measures: offloading. The 1/19/22 Skin/Wound care evaluation, documented by LPN #3 at 2:30 p.m., read in part: Skin and wound care evaluation today with the wound care team and the WP related to the patient's skin concerns to left heel. Measurements are length 3.4 cm x width 5.0 cm x depth undetermined-unstageable. Upon entry into room, no pad on bed to float heels. Patient states he kicked it out sometime earlier. WP discussed risks and benefits of offloading heels; pt (patient) voices understanding. This writer discussed offloading booties, will evaluate and place today. Wounds are progressing as expected. Eschar hardened, perimeter soft, discolored, suspected deep tissue injury initially, may appear larger. Using clean technique, wound care was done on patient as they were lying in bed. Treatments were then done per recommendation of WP. Patient did tolerate the wound care well and was then repositioned after to comfort with heels up pad in bed. Treatment orders are now up to date in chart as well as care plan. We discussed with patient the benefits of wound care and also the importance of regular skin treatment regimen. We educated related to the importance of protein and good caloric value needed to help their skin heal. Patient voiced no concerns at this time. Will continue to monitor closely. Staff updated. -From the discovery of the heel ulcer on 1/12/22 to 1/19/22 it had increased in size. VI. Staff interviews CNA #1 was interviewed on 1/24/22 at 3:00 p.m. She said Resident #24 was pleasant and cooperative and she had not had any issues with him being non-compliant with using the heels up pad once it had been started. He had not refused care at any time. RN #6 was interviewed on 1/24/22 at 5:00 p.m. She said Resident #24 had no pressure ulcers when he was admitted and she had not known him to be non-compliant with any care (however, this was not indicated in the resident's care plan, see above). She said if there were orders for weekly skin/foot, pain and Braden scale assessments, those were to be done by the nurse and a skin/foot assessment was to include examining all the skin, head to toe and documenting any abnormal findings. The DON was interviewed on 1/25/22 at 12:25 p.m. She said when a resident had an order for weekly skin/foot and Braden assessments, those were to be completed by the nurse as ordered. She said she thought Resident #24's heel area had initially started as a blister, however, there was no documentation to that effect. She said if there was an order for skin prep to be applied to the heels, that should be applied as well. She acknowledged that if the weekly skin assessments and his scheduled showers had been completed as they should have been the heel ulcer could have been caught earlier than it was and not have progressed to an unstageable pressure ulcer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to manage pain in a manner consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one (#221) of two residents out of 40 sample residents. Resident #221, who had diagnoses of low back pain, compression fractures in her lumbar and thoracic vertebrae, and left upper quadrant (abdominal) pain was admitted to the facility on [DATE]. The resident stated she had back pain and did not like to get out of bed much because she had more pain when she moved. The resident also stated that she ate most of her meals lying down in her bed because she had less pain when she was lying in bed. The comprehensive pain assessment completed upon admission to the facility documented the resident had sharp, continuous left flank pain which worsened with movement and made activities of daily living (those skills required to manage one's basic physical needs, including personal hygiene or grooming, dressing, toileting, transferring or ambulating, and eating), physical activity, and mobility more difficult. Furthermore, the pain assessment documented the resident's acceptable level of pain was a 3 on a scale of 1-10, with 10 being the worst possible pain. Daily skilled nurse's notes revealed the resident experienced a pain level greater than her stated acceptable pain level of 3 on 13 out of 20 days (between 1/5 and 1/24/22), with a pain level greater than 5 on several of those days. The resident received as needed pain medication, however, review of the follow-up pain levels after pain medication administration revealed the resident's pain frequently remained above her stated acceptable pain level of 3 and no further pain medication was administered. The resident had a physician's order for a scheduled pain patch which she would refuse at times. The facility failed to notify the physician that the resident was occasionally refusing her pain patch or that her pain levels remained greater than her stated acceptable level of pain following administration of pain medication. In addition, the facility failed to conduct weekly Comprehensive Pain Evaluation assessments per physician orders, and the physician, as well as the facility, did not address the resident's acceptable pain level until the pain concerns regarding the resident were brought to their attention. Due to the facility's failures, Resident #221 experienced pain greater than her stated acceptable pain level and stated she did not want to get out of bed because movement increased her pain. Findings include: I. Facility policy and procedures The Analgesia (pain) policy and procedure, last revised 2/8/21, was provided by the director of nursing (DON) via email on 1/25/22 at 1:37 p.m. It read in pertinent part, Upon admission, all patients will be evaluated for pain. Pain level will also be evaluated every shift. Once a patient expresses the perception of pain or makes a request for pain medication, the patient will be provided with a dose of analgesic pain medication or non pharmacological intervention will be initiated. It is the responsibility of the individual staff member that heard the complaint to follow up and make sure that some intervention (pharmacological or otherwise) is initiated. If a patient has an order for a pain medication from the hospital or one of our physicians, please use that order. Any scheduled pain medications should be given as close as time stated in medication administration record (MAR). If there is no order and the patient is experiencing pain, contact the physician immediately to obtain an order for analgesia. If no response is received timely, please call the medical director to obtain an order for analgesia. In the interim, attempt non-pharmacological modalities for pain control such as repositioning, touch therapy, biofeedback, distraction (television (TV), conversation etc.). -The policy did not address the need to follow-up with the physician if pain medications were ineffective in managing a resident's pain. II. Resident status Resident #221, age [AGE], was admitted on [DATE]. According to the January 2022 computerized physician orders (CPO), diagnoses included low back pain, wedge compression fracture of the fourth lumbar vertebra, wedge compression fracture of unspecified thoracic vertebra, malignant neoplasm of left main bronchus (one of two large tubes that carry air from the windpipe to the lungs), and left upper quadrant (abdominal) pain. The 1/9/22 minimum data set (MDS) assessment revealed that the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) of 12 out of 15. She required one-person limited assistance for bed mobility, transfers, ambulation, dressing, toilet use, and personal hygiene. The 1/9/22 MDS assessment further revealed that the resident received scheduled and as needed pain medications. She also received non-medication interventions for pain. She had moderate pain occasionally over the five day look back period of the assessment. III. Resident observations and interviews On 1/12/22 at 11:00 a.m., Resident #221 was lying in bed in a hospital gown. Resident #221 said she was admitted to the facility from the hospital and her back was broken. She said she experienced a lot of pain if she moved. Resident #221 said the nurses did give her pain medication but she still had pain when she moved. She said she did not like to get out of bed because of the pain. She said she ate most of her meals lying down in the bed, curled on her side because her back did not hurt so much when she was in that position. On 1/13/22 at 9:23 a.m., the resident was lying in bed curled on her left side. She said she was having pain in her back and she had not been out of bed much that morning. She said she did not want to get up because her back hurt when she moved. On 1/13/22 at 3:27 p.m., Resident #221 was again lying in her bed, curled on her left side. She said her back was hurting and she was waiting on the nurse to bring her pain medication. On 1/24/22 at 3:46 p.m., the resident was lying on her left side in bed. She said she did not hurt much as long as she did not move. As she rolled to her back she grimaced and reached toward the left side of her body. On 1/25/22 at 8:50 a.m., Resident #221 was lying in the bed on her back. The head of the bed was elevated and the resident was lying closer to the foot of the bed. She said she had just walked to the bathroom. She said she had pain in her back. She said she would rest for a few minutes to decrease the pain before she moved herself up toward the head of the bed. She was wincing and grabbing at her left side while she talked. Resident #221 said she was not sure if she had received pain medication that morning, but she thought the nurse had given her some. She said she saw a doctor on the prior day (1/24/22). She said the doctor told her she needed to get up and move more. IV. Record review Resident #221's history and physical completed by the hospital physician on 1/2/22 documented the following in pertinent part, Principal problem is intractable back pain. New thoracic compression fracture. Patient with pain radiating from back to left lower chest wall. Patient has been given a brace in the past but declines to wear the brace. Will focus on pain control. Tylenol and Ultram (Tramadol) for pain control. Lidocaine patch as needed. Previous medical history of osteoporosis and previous compression fractures of the thoracic and lumbar spine, lung cancer status post chemotherapy and radiation who has presented for the past three days with increasing pain radiating from her back to her left lower chest wall. The patient states it feels okay if she lays still and doesn't move but anytime she moves the pain is magnified. It is a dull pain. The January 2022 CPO revealed Resident #221 had the following orders for pain management: -Tramadol HCl tablet 50 milligrams (mg) one tablet by mouth every six hours as needed for pain levels of 5-10. The order date was 1/4/22; -Tylenol Extra Strength tablet (Acetaminophen) 500 mg two tablets by mouth every six hours as needed for pain levels of 1-4. The order date was 1/4/22. The order was discontinued on 1/9/22. -Acetaminophen tablet 650 mg by mouth every four hours as needed for pain. The order date was 1/9/22; -Lidocaine Patch 4 %. Apply to the affected area topically one time a day for pain management and remove per schedule. The order date was 1/4/22. The order was discontinued on 1/20/22; -Lidocaine Patch 5 %. Apply to the affected area topically one time a day for pain management, remove each night per schedule. The order date was 1/20/22; -Offer non-pharmacological interventions throughout the shift to include: ice, re-positioning, elevation, relaxation, rest, etcetera. The order date was 1/4/22. (The January 2022 electronic medication administration record (EMAR) documented the interventions were being offered every shift); -Evaluation of pain every shift and document for routine screening. The order date was 1/4/22; and, -Comprehensive Pain Evaluation every week for routine screening. The order date was 1/4/22. Review of Resident #221's comprehensive care plan, initiated 1/5/22, revealed she had acute/chronic pain related to spinal fractures. Pertinent interventions included acknowledging the presence of pain and discomfort, listening to the patient's concerns as needed, administering pain medications per the physician's orders and noting their effectiveness, implementing non-pharmacological interventions when able such as: positioning/support, exercise/stretching, ice packs/moist hot pack application, and relaxation, monitoring for pain every shift and as needed, and notifying the physician as needed of any changes. The pain section of the Nursing Comprehensive admission Data Collection assessment dated [DATE] documented Resident #221 had sharp, continuous left flank/back pain upon admission. The resident rated her pain at 5 out of 10 on the numeric pain scale (on a scale of 1-10, with 10 being the worst pain). The 1/4/22 admission assessment further documented the resident's pain was alleviated by pain medication, rest, and repositioning. The resident's pain worsened with movement and made activities of daily living (those skills required to manage one's basic physical needs, including personal hygiene or grooming, dressing, toileting, transferring or ambulating, and eating), physical activity, and mobility more difficult. Further review of the 1/4/22 admission comprehensive pain assessment revealed Resident #221 stated her acceptable pain level was 3 out of 10 on the numeric pain scale. Review of Resident #221's January 2022 EMAR revealed she had a physician's order to have a Comprehensive Pain Evaluation assessment completed on 1/11/22 and 1/18/22. -The order was not signed off on the EMAR to indicate the assessment had been completed on 1/11/22 and there was no Comprehensive Pain Evaluation assessment found in the resident's electronic medical record (EMR) for 1/11/22. -The order was signed off on the EMAR to indicate the assessment had been completed on 1/18/22, however there was no Comprehensive Pain Evaluation assessment found in the resident's EMR for 1/18/22. -Review of Resident #221's January 2022 EMAR from 1/5/22 through 1/24/22 revealed the daily pain assessment was not documented as completed on the day shift on 1/5, 1/10, 1/11, and 1/23/22. Review of Resident #221's Daily Skilled Nurses's Notes from 1/5 through 1/24/22 revealed the following, in pertinent part: 1/5/22: There was no daily skilled nurse's note documented. 1/6/22: Pain rating out of 10: 7. 1/7/22: Pain rating out of 10: 6. 1/8/22: Pain rating out of 10: 7. 1/9/22: Pain rating out of 10: 8. 1/10/22: Pain rating out of 10: 7. 1/11/22: Pain rating out of 10: 5. Patient reports that if she is not moving she has no pain, but any movement causing increased pain. 1/12/22: Pain rating out of 10: 6. Patient reports when moving around in bed. 1/13/22: Pain rating out of 10: 4. 1/14/22: Pain rating out of 10: 4. 1/15/22: Pain rating out of 10: 0. 1/16/22: Pain rating out of 10: 6. 1/17/22: Pain rating out of 10: 4. Does not want to move much due to pain issues. 1/18/22: Pain rating out of 10: 4. Goes up with movement. 1/19/22: Pain rating out of 10: 0. It only hurts when I move. 1/20/22: Pain rating out of 10: 0. 1/21/22: Pain rating out of 10: 0. 1/22/22: Pain rating out of 10: 0. 1/23/22: Pain rating out of 10: 5-10. Moving increases pain. 1/24/22: Pain rating out of 10: 2. Unless moving around. -The above documentation revealed Resident #221 experienced a pain level greater than her stated acceptable pain level of 3 on 13 out of 20 days. -Despite documentation that movement increased the resident's pain, there was no documentation of the physician being notified to request additional orders for pain control. Further review of Resident #221's electronic medical record revealed the following progress notes: 1/7/22: A progress note from the facility's physician documented in pertinent part: Back pain has improved. Pain level 6 out of 10. -The pain level documented in the progress note was greater than the resident's stated acceptable pain level of 3. 1/14/22: A progress note from the facility's physician documented in pertinent part: Back pain has improved. Pain level 6 out of 10. -The pain level documented in the progress note was greater than the resident's stated acceptable pain level of 3. 1/15/22: A progress note from the facility psychologist documented in pertinent part: Subjective: 'I cannot move it hurts right here; I have an ulcer.' I asked if she was hungry, and she tells me she is but could not sit up. She turns slightly on her side and wants her plate on the bed. I set-up breakfast for her and she was eating when I left. I went back to check on her and we talked about what happened. I told her per her chart she fell and where it hurts, she has a fracture. She tells me she is not sleeping well. 1/19/22: A progress note from the facility's physician documented in pertinent part: Back pain. Pain level 0 out of 10. Patient reports it only hurts when she moves. -Despite the resident stating it only hurt when she moved, there was no documentation to indicate the physician addressed the need for more effective pain management in order to enable the resident to be more active. 1/21/22: A progress note from the facility's nurse practitioner documented in pertinent part: Today she reports minimal to moderate back pain at times. Pain level is 5. She stated it only hurts when she moves. -The pain level documented in the progress note was greater than the resident's stated acceptable pain level of 3. -Despite the resident stating it only hurt when she moved, there was no documentation to indicate the nurse practitioner addressed the need for more effective pain management in order to enable the resident to be more active. 1/22/22: A progress note from the facility psychologist documented in pertinent part: Subjective: I told her she looked good walking today. ' Yes, but it still hurts. My side really hurts now. I really want to go home so I hope in four or five days it is better and does not hurt so much. ' She went on to tell me her son can not visit as he has COVID-19. Review of Resident #221's January 2022 EMAR for pain medication administration from 1/5 through 1/24/22 (20 days) for pain levels 4 and above, revealed 11 days with failures for ineffective pain management. The findings were as follows: 1/5/22 at 7:32 p.m: As needed (PRN) Tylenol 1000 mg was administered for a pain level of 4. The medication was documented as ineffective with a follow-up pain level of 6, which was greater than the resident's stated acceptable pain level of 3. -The resident had a physician's order for Tramadol 50 mg every six hours PRN for a pain level of 5-10, however no further pain medication was administered, and there was no notification to the physician regarding ineffective pain management. 1/7/22 at 7:15 a.m: PRN Tramadol 50 mg was administered for a pain level of 7. The medication was documented as effective, however the follow-up pain level was documented as a 6, which was greater than the resident's stated acceptable pain level of 3. -The resident had a physician's order for Tylenol 1000 mg every six hours PRN for a pain level of 1-4, and the PRN Tramadol could be administered every six hours, however no further pain medication was administered until 8:47 p.m., and there was no notification to the physician regarding ineffective pain management. 1/9/22 at 10:48 a.m: PRN Tylenol 1000 mg was administered for a pain level of 8. The medication was documented as unknown effectiveness (indicating the resident's pain was not assessed following the pain medication administration). -The resident had a physician's order for Tramadol 50 mg every six hours PRN for a pain level of 5-10, however Tylenol was administered despite the resident stating her pain level was 8. 1/9/22 at 1:28 p.m: PRN Tramadol 50 mg was administered for a pain level of 8. The medication was documented as unknown effectiveness (indicating the resident's pain was not assessed following the pain medication administration). -There was no further pain medication administered to the resident until 10:28 p.m. 1/13/22 at 4:30 p.m: PRN Tramadol 50 mg was administered for a pain level of 7. The medication was documented as effective, however the follow-up pain level was documented as a 5, which was greater than the resident's stated acceptable pain level of 3. -The resident had a physician's order for Tylenol 650 mg every four hours PRN, and the PRN Tramadol could be administered every six hours, however no further pain medication was administered, and there was no notification to the physician regarding ineffective pain management. 1/14/22: The resident's daily pain assessment was documented as a pain level of 4, which was greater than the resident's stated acceptable pain level of 3, for both the day shift and the night shift. -Despite the resident's pain levels being greater than her stated acceptable pain level of 3, there was no PRN pain medication administered on 1/14/22, and the resident had also refused her scheduled Lidocaine patch. 1/16/22 at 5:30 a.m: PRN Tramadol 50 mg was administered for a pain level of 5. The medication was documented as unknown effectiveness (indicating the resident's pain was not assessed following the pain medication administration). -There was no further pain medication administered to the resident until 7:21 p.m. 1/16/22 at 7:21 p.m: PRN Tramadol 50 mg was administered for a pain level of 8. The medication was documented as effective, however the follow-up pain level was documented as a 4, which was greater than the resident's stated acceptable pain level of 3. -The resident had a physician's order for Tylenol 650 mg every four hours PRN, and the PRN Tramadol could be administered every six hours, however no further pain medication was administered, and there was no notification to the physician regarding ineffective pain management. 1/18/22: The resident's daily pain assessment was documented as a pain level of 7, which was greater than the resident's stated acceptable pain level of 3, for both the day shift and the night shift. -Despite the resident's pain levels being greater than her stated acceptable pain level of 3, there was no PRN pain medication administered on 1/18/22. 1/21/22 at 2:50 p.m: PRN Tramadol 50 mg was administered for a pain level of 8. The medication was documented as effective, however the follow-up pain level was documented as a 5, which was greater than the resident's stated acceptable pain level of 3. -The resident had a physician's order for Tylenol 650 mg every four hours PRN, however no further pain medication was administered until 6:05 p.m., and there was no notification to the physician regarding ineffective pain management. 1/22/21 at 11:52 a.m: PRN Tramadol 50 mg was administered for a pain level of 7. The medication was documented as effective, however the follow-up pain level was documented as a 4, which was greater than the resident's stated acceptable pain level of 3. -The resident had a physician's order for Tylenol 650 mg every four hours PRN, however no further pain medication was administered until 5:38 p.m., and there was no notification to the physician regarding ineffective pain management. 1/23/22: The resident's daily pain assessment was not documented, however the Daily Skilled Nurse's Note documented Pain rating out of 10: 5-10. Moving increases pain. -Despite the nurse's note documenting the resident was experiencing pain levels of 5-10, there was no pain medication administered to the resident on 1/23/22. 1/24/22 at 5:23 p.m: PRN Tylenol 650 mg was administered for a pain level of 8. The medication was documented as effective, however the follow-up pain level was documented as a 5, which was greater than the resident's stated acceptable pain level of 3. -The resident had a physician's order for Tramadol 50 mg every six hours PRN for a pain level of 5-10, however Tylenol was administered despite the resident stating her pain level was 8. -The resident had a physician's order for Tramadol 50 mg every six hours PRN for a pain level of 5-10, and the PRN Tylenol could be administered every four hours, however no further pain medication was administered, and there was no notification to the physician regarding ineffective pain management. Further review of Resident #221's eMAR for pain medication administration for 1/5 through 1/24/22 revealed the resident refused application of her Lidocaine patches on 1/11, 1/12, 1/14, and 1/24/22. -The Lidocaine patch was documented as no coverage needed on 1/13 and 1/15/22. -There was no documentation which indicated the physician had been notified the resident was refusing her Lidocaine patches on occasion. V. Interviews The certified occupational therapy assistant (COTA) was interviewed on 1/25/22 at 8:59 a.m. The COTA said it required good timing with Resident #221 to encourage her to get up and participate with therapy. She said the resident did not like to get up much, but sometimes she was willing to get up. The COTA said the resident had pain when she moved, but she said a lot of the time patients had pain memory. She said patients thought it was going to hurt so they did not want to move, but once the patient got moving, he or she discovered it did not hurt as much as they thought it was going to hurt. The COTA said she thought Resident #221 received pain medication, but she did not know what medication she received or how often she received it. Certified nurse aide (CNA) #9 was interviewed on 1/25/22 at 9:03 a.m. CNA #9 said Resident #221 did not like to be out of bed much, however she would get up and sit in her recliner at times. She said the resident would usually put herself back into bed though. She said the resident had pain in her left side and she had more pain when she moved. CNA #9 said when the resident complained of pain, she told the nurse and the nurse would give her pain medication. She said the resident would still have pain when she moved. CNA #9 said Resident #221 would often eat lying down in bed because it helped her pain not to be sitting up. Licensed practical nurse (LPN) #2 was interviewed on 1/25/22 at 12:22 p.m. LPN #2 said she would ask a resident if they were having pain when she administered their scheduled medications. She said if the resident indicated they had pain, she would ask them what their pain level was and administer PRN pain medication to them. LPN #2 said she would follow up with the resident about an hour after the pain medication was administered to see if the pain medication had been effective. She said if they were still complaining of a higher pain level than was acceptable for them she would consider the pain medication ineffective. She said she would see if the resident had another pain medication that could be given. LPN #2 said if they did not have another pain medication she would inform the charge nurse who would call the physician for orders for more effective pain medication. She said Resident #221 often complained of having pain mostly with movement. She said she received PRN pain medications. LPN #2 said the resident also had a pain patch but she sometimes refused it. She said had refused the patch that morning (1/25/22) because she was going to take a shower. Registered nurse (RN) #4 was interviewed on 1/25/22 at 10:04 a.m. RN #4 said residents should be assessed for pain whenever a nurse was in the resident's room. She said if a CNA noticed a resident was having pain they should alert their nurse so pain medication could be administered. RN #4 said a lot of the facility's residents came in with pain from surgical procedures, broken bones, etcetera, so managing pain was very important. She said if a resident was given pain medication, the nurse should follow up with them in an hour to an hour and a half and see if the medication was effective. RN #4 said pain levels were very individually based for residents, but a resident usually had a pain level that they said was acceptable. She said if the follow-up pain level was above that acceptable pain level, the nurse should administer another pain medication if the resident had one. RN #4 said nurses were supposed to let her know if pain medication was not effective for a resident and she would call the physician to see what type of new orders could be obtained for pain management. The DON was interviewed on 1/25/22 at 12:29 p.m. The DON said pain was different for individual residents. She said nurses completed an initial comprehensive pain assessment on every resident upon their admission to the facility. She said the assessment included documenting the resident's acceptable pain level. She said the facility utilized non-pharmacological interventions such as rest, ice, and heat, as well as opioid and non-opioid medications for effective pain management. The DON said nurses should follow up with a resident after administering a pain medication and if the resident's pain level continued to be above their acceptable pain level, the nurse should administer another pain medication if the resident had orders for one. She said if the resident did not have another pain medication order, and the resident needed better pain management, the charge nurse should call the physician for further orders. She said if a pain regimen was deemed ineffective, then a different pain regimen should be obtained in order to manage the resident's pain. The DON said she had been in Resident #221's room on several occasions and the resident did not complain very often. She acknowledged that just because a resident did not complain, that did not necessarily mean the resident did not have pain. The DON acknowledged the nurses had a responsibility to ensure they were properly assessing and managing residents ' pain, however she said the responsibility also belonged to the physician because they looked at the resident's medical record as well. VI. Facility follow up On 1/26/22, after the survey, the nursing home administrator (NHA) provided, via email, a physician's progress note dated and a handwritten note from RN #4. The physician's progress note was dated 1/25/22 at 1:50 p.m. (one hour and 21 minutes following the interview with the DON). The progress note documented the physician's visit with Resident #221. It documented in pertinent part, Pain rating 2 out of 10, 10 when moving around. Pain level is acceptable at 4 out of 10. Usual pain level has been 4 out of 10. Pain is getting better. On pain medications, will avoid extra narcotics, use Tylenol PRN. -The physician did not address Resident #221's acceptable pain level (which had been a 3 since admission on [DATE]) until the pain management concern was brought to the facility's attention. In addition, the physician did not address when the resident's pain level was 5-10 and when PRN Tramadol was not administered according to the orders or when the scheduled Lidocaine patch was refused by the resident, which was part of her pain management regimen. Furthermore, the physician did not schedule any additional pain medication, such as Tylenol after this visit on 1/25/22. The handwritten note from RN #4 was dated 1/26/22 and documented in pertinent part, I went to see the Resident #221 to ask her about her acceptable level of pain and her answer was 4. She said bad pain for her was 8 out of 10. The note was signed by RN #4. -The facility did not address Resident #221's acceptable pain level (which had been a 3 since admission on [DATE]) until the pain management concern was brought to the facility's attention.