**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff and resident interviews, and review of the facility policy titled Comprehensive Care Plan, the facility failed to follow the person-centered care plan to ensure pain interventions were implemented during wound care for one resident (R) (#43), resulting in harm to the resident, of 30 sampled residents. Findings include: A review of the facility policy, Comprehensive Care Plans, implemented 2/1/22, revealed the facility would implement a comprehensive person-centered for each resident, consistent with resident rights, to meet each resident medical and nursing needs. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE], Section - C -Cognition, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating cognition intact. Section M-Skin Conditions revealed R#43 had a surgical wound and received surgical wound care. Section O-Special Treatments and Programs revealed R#43 received Hospice care. Section J-Health Conditions revealed R#43 was on a scheduled pain regimen and pain was reported her pain as frequent in nature. Section N-Medications revealed R#43 received opioids for the last seven days of the assessment period. A review of R#43's care plan entitled, Hospice Services, initiated 11/11/21, revealed pain medications would be administered as ordered and observed for effectiveness. A review of R#43's care plan entitled, Pain, initiated 1/29/22, revealed analgesics should be administered prior to treatment or care as indicated. Staff should anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Further review revealed an evaluation of the pain intervention's effectiveness should be reported to the MD (Medical Doctor) if observed ineffective. Additionally, staff would plan pain management before treatments to ensure maximum comfort and provide unhurried care. During an observation on 5/21/22 at 6:07 p.m. of the 200 hall, groans were heard coming from R#43's room. Upon entry to the room, R#43 was positioned on her right side. Registered Nurse (RN) DD was behind the resident, and the Licensed Practical Nurse (LPN) FF assisted in positioning the resident on her side. R#43 was screaming, it hurts, please stop. RN DD stated she was done and only needed to apply the bandage to the wound. During an interview with R#43 on 5/21/22 at 6:07 p.m., she stated her pain was a 12 out of 10. RN DD did not pre-medicate or assess her pain before the wound treatment. R#43 explained that she told RN DD that she was in pain, but RN DD did not stop the treatment or ask her if she wanted her to stop. During an interview with RN DD on 5/21/22 at 6:08 p.m., she stated she had worked at the facility since September 2021. RN DD stated that R#43 was on routine pain medications, but she was unsure when R#43 had received her pain medication. RN DD acknowledged she did not know what pain medication or dosage R#43 received before she began her treatment. RN DD explained she did not stop the wound care when R#43 told her to stop because it was towards the end of her shift, and she wanted to ensure the treatment was done before leaving for the day. She added it was important for R#43 to have the wound treatment due to the nature of the wound. RN DD confirmed that R#43 was screaming in pain and stated she should have stopped the treatment and addressed her pain before continuing with the treatment. A review of the Nursing Progress Notes dated 5/21/22 at 7:00 p.m. revealed that while performing wound care, R#43 was yelling out in pain at the onset of positioning and wound care. R#43 continued to vocalize her pain until the completion of the treatment. Per the note, R#43 was not offered or administered additional pain medication during the treatment. Cross refer to F697.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff and resident interviews, and review of facility policy titled Pain Management, the facility failed to stop and address one resident's expression of severe pain during a wound treatment, resulting in harm for resident #43, of 30 sampled residents. Findings include: A review of the facility policy, Pain Management, implemented 2/2/22, revealed the facility would recognize circumstances and situations when a resident's pain could be anticipated. Per the policy, the facility would manage or prevent pain with the comprehensive plan of care, professional standards of practice, and the resident's preferences. Continued review revealed interventions for pain management would be incorporated into the comprehensive care plan and would address specific pain management needs or goals. Pharmacological interventions included reviewing clinical conditions which might require several analgesics and/or adjuvant medications, and facility staff would notify the practitioner if the resident's pain was not controlled with the ordered medications. A medical record review revealed that R#43 was admitted on [DATE] with a past medical history of right humeral fracture, falls, dizziness, hypokalemia, hyponatremia, surgical wound, and lumbar pain. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE], Section - C -Cognition, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating cognition intact. Section M-Skin Conditions revealed R#43 had a surgical wound and received surgical wound care. Section O-Special Treatments and Programs revealed R#43 received Hospice care. Section J-Health Conditions revealed R#43 was on a scheduled pain regimen and pain was reported her pain as frequent in nature. Section N-Medications revealed R#43 received opioids for the last seven days of the assessment period. A review of R#43's comprehensive person-centered care plan entitled, Pain, initiated 1/29/22, revealed analgesics should be administered prior to treatment or care as indicated. Staff should anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Further review revealed an evaluation of the pain intervention's effectiveness should be reported to the MD (Medical Doctor) if observed ineffective. Additionally, staff would plan pain management before treatments to ensure maximum comfort and provide unhurried care. A review of the Physician Orders for R#43 revealed the following: 3/27/22 - admitted to Hospice. 3/28/22 - acetaminophen 650 milligrams (mg) to be inserted rectally every six hours for pain or fever as needed. 5/12/22 - Naproxen 250 mg to be given by mouth every 12 hours for pain for 14 days. 5/19/22 - Dilaudid 8 mg to be taken by mouth every six hours for pain. A review of the facility, Administrative History Report, dated 5/21/22, revealed that Registered Nurse (RN) DD administered R#43's wound care. A review of the Medication Administration Record (MAR) revealed that R#43 received her scheduled Dilaudid 8 mg by mouth on 5/21/22 at 5:45 p.m. During an observation on 5/21/22 at 6:07 p.m. of the 200 hall, groans were heard coming from R#43's room. Upon entry to the room, R#43 was positioned on her right side. RN DD was behind the resident, and the Licensed Practical Nurse (LPN) FF assisted in positioning the resident on her side. R#43 was screaming, it hurts, please stop. RN DD stated she was done and only needed to apply the bandage to the wound. During an interview with R#43 on 5/21/22 at 6:07 p.m., she stated her pain was a 12 out of 10. RN DD did not pre-medicate or assess her pain before the wound treatment. R#43 explained that she told RN DD that she was in pain, but RN DD did not stop the treatment or ask her if she wanted her to stop. During an interview with RN DD on 5/21/22 at 6:08 p.m., she stated she had worked at the facility since September 2021. RN DD stated that R#43 was on routine pain medications, but she was unsure when R#43 had received her pain medication. RN DD acknowledged she did not know what pain medication or dosage R#43 received before she began her treatment. RN DD explained she did not stop the wound care when R#43 told her to stop because it was towards the end of her shift, and she wanted to ensure the treatment was done before leaving for the day. She added it was important for R#43 to have the wound treatment due to the nature of the wound. RN DD confirmed that R#43 was screaming in pain and stated she should have stopped the treatment and addressed her pain before continuing with the treatment. During an interview with LPN FF on 5/21/22 at 6:09 p.m., she acknowledged she heard R#43 moaning and crying due to pain during the treatment. LPN FF stated she encouraged R#43 to hold and squeeze her hand during the treatment. LPN FF acknowledged she did not check to see if there was a medication they could give R#43. During an interview with Charge Nurse (RN) EE on 5/21/22 at 6:14 p.m., he stated his expectation of RN DD would have been to stop the treatment and check for a PRN pain medication. RN EE explained that after a resident is medicated, his expectation is for the nurse to wait an appropriate time for the pain medications to work and reassess the resident's pain before proceeding with treatment. RN EE explained that R#47 is in Hospice. If no PRN medication were available for R#47, he would expect the nurse to call the Hospice nurse to explain the resident is in pain during the treatment and get an order for something for pain. An observation of RN EE on 5/21/22 at 6:13 p.m. revealed the nurse evaluating R#43's pain. She stated her pain rating was an 8 out of 10. RN EE told R#43 he would call about getting her something for her pain. During a follow-up interview with R#43 on 5/21/22 at 6:30 p.m., she reported her pain level was 8 out of 10. She indicated she was in pain but stated it lessened since the wound treatment stopped. R#43 explained that she told RN DD that she was in pain as soon the wound treatment began, and she asked her to stop. She could not remember what RN DD said in response to asking her to stop because she was in too much pain to recall the conversation. She only remembered that RN DD did not stop. She explained that there had been times she had asked a nurse to stop during the treatments, and they would stop and give her something for pain and come back later. She stated it helped when she was given something for pain, and the treatment wouldn't hurt as badly. She said that sometimes the nurses don't stop when she asks them to. A review of the Nursing Progress Notes dated 5/21/22 at 7:00 p.m. revealed that while performing wound care, R#43 was yelling out in pain at the onset of positioning and wound care. R#43 continued to vocalize her pain until the completion of the treatment. Per the note, R#43 was not offered or administered additional pain medication during the treatment. During a telephone interview with Hospice nurse (RN) GG on 5/22/22 at 2:34 p.m., she stated it is her expectation for facility nursing staff to call the on-call Hospice nurse if a resident is experiencing pain and requires a PRN pain medication. RN GG explained that it is not uncommon to have facility nurses call the on-call Hospice nurse for residents' needs. She added that Hospice nurses are available 24 hours a day and seven days a week to provide support to their Hospice clients. During an interview with the DON on 5/22/22 at 3:47 p.m. she stated it was her expectation of the nursing staff to properly medicate residents for pain prior to any treatments. She added that if there is no PRN medication for pain, she expected the nurse to call the MD. If a patient is on Hospice, the nurse could also call Hospice for a PRN medication. She explained that if a resident told a nurse to stop a treatment for any reason, she expected the nurse to stop. She said that nurses should be assessing for pain before, during, and after all treatments. She stated any changes in condition should be reported to her in case a resident's plan of care needed to be adjusted.