Based on observation, interview and record review the facility failed to comprehensively assess pain and effectively manage pain for one resident (R67) of three residents be reviewed for pain. This failure has resulted in ineffective pain management and ongoing expression of moderate to severe pain by R67. Findings include: The Facility's Pain Management Policy dated 3/26/21 documents: It will be the standard of this facility to screen residents and attempt to provide effective pain and comfort management. Residents may additionally be screened for pain quarterly, annually, upon change of condition or upon resident report of new pain or newly observed non-verbal signs and symptoms of potential pain. On-going monitoring of residents receiving interventions should be completed in the clinical record, as indicated. Implement/update a person-centered care plan of care related to pain management as is appropriate. R67's Hospital Discharge Note dated 12/31/23 indicates R67 reported generalized and buttock pain score 10/10 (scale 0 = no pain; 1 to 3 = mild pain; 4 to 7 = moderate pain; and 8 or above is severe pain) five times prior to receiving Acetaminophen 650mg (milligrams) and reported generalized and buttock pain of 6/10 three times and 10/10 twice prior to receiving Tramadol (analgesic). Follow up pain relief/response to administration of Tramadol was documented as 1 to 4/10 indicating effectiveness of medication. R67's admission Nursing Note Pain Screen dated 12/31/23 at 3:19pm indicates R67 indicated she was experiencing generalized pain 7/10. Note indicates R67's pain is relieved by medication management and repositioning. R67's Physician Note dated 1/2/24 indicates R67 was previously bedridden at home due to Arthritis. Note indicates R67 has arthritic changes in her hands, knees, and feet. Note indicates R67 reports severe pain with turning when wound care is done and reports the pain is in her legs. Note indicates R67 reports pain is 10/10 all over in all joints. R67's Physician Note dated 2/7/24 indicates R67 has a Stage 4 sacral pressure wound, full thickness. R67's Physician Note dated 2/16/24 indicates R67 states that she continues to have pain with any kind of transitioning or rotation in bed and that R67's mood is fine when she is otherwise lying still related to her arthritis. Note indicates (R67) has pretty significant pains and discomfort of the large coccyx wound. On 3/13/24 at 9:35am R67 was turned onto her side to receive sacral wound care. R67 was distressed with facial grimacing, stiffening, guarding, and reporting pain throughout her lower body. While on her side during wound care R67 continued to intermittently complain of pain. R67 cried out and whimpered when V4 (Wound Nurse) removed the wound vac sponge from inside R67's sacral wound, cleaned inside R67's sacral wound and inserted a new wound vac sponge into R67's sacral wound. V4 attempted to console R67 during the wound treatment to which R67 replied No, you don't know. It's horrible. At that time V4 reminded R67 that she had received a Norco (opioid) earlier in the morning (7:40am) to help with the pain. R67 replied that the pain was still there. On 3/13/24 at 1:40pm R67 stated I have chronic arthritis everywhere, particularly my knees and feet. My knees are throbbing right now. I'm up all night sometimes, I can't sleep because I'm uncomfortable. Then I sleep on/off during the day because I'm tired from not sleeping at night. The worse pain is in my coccyx, then knees and feet. Even the slightest movement is severe pain. I used to ask for the Norco in the evening, but I became really constipated. It was like having a baby - really painful also causing pressure and pain in my coccyx. While R67 described her pain she became tearful and expressed how she tries not to complain. R67 stated her pain was 9 or 10 out of 10 during wound treatments stating, It feels like they are pulling my skin off. R67 stated the Norco she received at 7:40am (prior to wound care) did not really help much and barely takes the edge off. R67's current Physician Order Summary Report indicates R67 has orders for: Hydrocodone-Acetaminophen 5-325mg (milligrams), Give one tablet every day shift for pain - to be given one half hour prior to wound treatment. Hydrocodone-Acetaminophen 5-325mg every six hours as needed for moderate pain. Acetaminophen 650mg every six hours as needed for general discomfort. R67's MAR (Medication Administration Record) dated 2/1/24 to 2/29/24 and 3/1/24 to 3/13/24 indicates R67 received Hydrocodone-Acetaminophen 5-325mg for pain prior to wound care. MARs indicate R67 reported pain level 8/10 seven times, 9/10 twelve times and 10/10 seven times prior to administration of Hydrocodone prior to the wound care. R67's MAR dated 2/1/24 to 2/29/24 indicates R67 received as needed Hydrocodone-Acetaminophen 5-325mg on 2/1, 2/3, 2/4, 2/5, 2/6 and 2/7/24 in the evenings for reports of pain 6 - 8/10. R67's MARs indicate R67 only received as needed Acetaminophen 650mg on 2/9/24 for pain level of 4/10 and on 3/4/24 for pain level of 9/10. R67's MARs also indicate R67 is monitored for pain every shift and scored zero (no pain) every shift on every day from 2/1/24 to 3/13/24 even though R67 had expressed pain and received pain medication on the above dates listed. Weekly Wound Progress Notes dated 2/15/24, 2/22/24 and 2/29/24 indicates R67 reported pain of 10/10 during sacral wound care on all the above dates. Notes dated 2/22/24 and 2/29/24 indicate R67 had the following non-verbal indicators of pain: Negative vocalizations (i.e., moaning, groaning, crying, calling out) Facial expressions (i.e., grimacing, frown, sad) Body language (i.e., tensed, distressed, pacing, fists clenched, striking out, knees pulled up, guarding) consolability [sic] (i.e., distracted, unable to console). R67's Weekly Wound Progress Note dated 3/6/24 indicates R67 reported pain level of 5/10 during wound care and exhibited negative vocalizations. On 3/14/24 at 1:00pm V2 (Director of Nursing/DON) stated she could not explain why R67's every shift pain score was zero yet R67 reported pain level of 10/10 during wound care and pain score prior to wound treatment was usually 6-10. V2 also stated there was no further assessment of R67's pain after reporting pain 10/10 during wound care. R67's NP (Nurse Practitioner) note dated 3/13/24 indicates R67 has osteomyelitis of coccyx and Stage 4 sacral wound. Note indicates R67 is seen in her room as she has reported uncontrollable pain. Note indicates she has been offered additional Norco but has refused due to fear of constipation. Discussed a long-acting Tylenol for pain and R67 is agreeable to a trial of standard release Tylenol scheduled every 8 hours. Note indicates an additional Hydrocodone (narcotic) with Acetaminophen in the evening for severe pain if she needs and if she allows it to be given. Note indicates additional options for constipation were also discussed. Note indicates R67 has a history of refusing narcotic pain medications. R67's Care Plan (date initiated 12/31/23) documents Potential/Actual pain related to Arthritis. Interventions include Monitor and Report signs and symptoms of pain, worsening of pain; notify physician if resident does not state/demonstrate relief or reduction of pain with current pain management regimen. This same care plan does not include history of R67 refusing pain medications, locations/characteristics of pain or non-pharmacologic interventions to assist in alleviating pain. On 3/14/24 at 1:30pm V2 (DON) stated R67 has had a history of refusing pain medications. V2 was unable to provide a comprehensive assessment of R67's pain (after admission assessment) and/or documentation/assessments of R67's refusal of pain medications offered. On 3/14/24 at 1:30pm V9 (Nurse Practitioner) stated she was unaware R67 had been taking (as needed) Norco every evening and abruptly stopped (on 2/8/24) due to becoming constipated. V9 stated that as of yesterday R67 has orders for scheduled Tylenol and an additional Hydrocodone as well as review of bowel medications to address R67's constipation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to notify the physician for an identified sign of infection in a pressure ulcer for one resident (R7). The facility also failed to identify a pressure ulcer and notify the physician for one resident (R18). These failures effected two out of four residents reviewed for pressure ulcer in a sample of 47. This failure caused a delay in treatment resulting in R7 being admitted to the Intensive Care Unit (ICU) for septic shock due to an infection in his stage IV right hip pressure ulcer. Findings include: The facility's Standards and Guidelines: SG Wound Care policy dated 3/27/21, documents 11. Document the progression of the wound being treated. Such observations should be items size, staging (if applicable), odors, exudate, tunneling, etiology etc. 12. Contact the physician for additional order changes as appropriated or to notify of skin condition changes or refusals of care. 1. On 02/14/23 at 12:14 PM, V4 (Licensed Practical Nurse/LPN), stated (R7) isn't here, he had an appointment this morning at the wound clinic, but he's not coming back. I was just informed the wound clinic sent him to the emergency room (ER) due to an elevated heart rate, low blood pressure and fever. They think he may have sepsis. R7's wound assessment dated [DATE] documents Left hip pressure ulcer stage IV and Right hip pressure ulcer stage IV. R7's physician order sheet dated 2/6/23 documents Change wound vacuum to left and right ischial ulcers using black foam at 175 millimeters of mercury (mmhg) for left 125 mmhg for right continuous changing three times a week and utilize xeroform, with a bordered gauze changing three times per week to his left lower extremity. (Wound solution, a mixture of sodium hypochlorite (0.4% to 0.5%) and boric acid (4%) diluted in water) soak for five to ten minutes with dressing changes. Cleansing all wounds with normal saline or wound wash of choice with dressing changes. 2/13/23 12:16pm R7's medical record documents Late Entry: Note Text: Wound vacuum to right and left hip changed per orders. Right hip noted to have foul smell and necrotic tissue. Resident to follow up with wound clinic on 2/14/23. Resident denies any pain at this time. Will continue to monitor. V29's (Medical Director) physician visit note dated 2/7/23 document's Of note, (R7) also reportedly had a seizure in the setting of acute infection in October. Of note, upon further review of his chart, it appears that he was admitted locally in October 2022 with sepsis and seizure like activity requiring intubation for airway protection. During that hospitalization, he underwent bilateral ischial wound debridement with left ischial bone biopsy by general surgery. Cultures grew klebsiella pneumoniae, proteus mirabilis, enterococcus faecalis, enterococcus faecium, corynebacterium, bacteroids thetaiotaomicron. Surgical pathology was consistent with necrotic skin and soft tissue with acute inflammation and acute osteomyelitis. On 2/14/23 2:11 PM, V7 (Wound Clinic Registered Nurse/WCRN), I was the one that saw him today. (V28 Nurse Practitioner), assessed his wounds and he had signs of infection in his right hip wound along with a low blood pressure, elevated heart rate and fever, so she had him sent to the ER for possible sepsis. If the facility identified a foul smell with necrotic tissue yesterday during his wound vacuum dressing change, they should have contacted us prior to putting the wound vacuum back on because his symptoms indicated an infection. 2/14/23 at 2:24 PM, V3 (Assistant Director of Nursing/ADON), stated I changed the wound vacuum yesterday and noticed the wound had a foul smell with some necrotic tissue. When I changed it yesterday, I knew he had an appointment today, so I didn't contact the wound clinic or his physician because I knew he was going to the wound clinic today. Yes, the foul smell and necrotic tissue typically indicates an infection. If the resident is being followed by a wound clinic, we normally notify the clinic of any wound changes, but like I said, he was being seen the next day and that's why I didn't. I guess it was just poor communication of why I didn't notify anyone. On 02/15/23 at 9:17 AM V7 (WCRN) stated After our conversation yesterday, I spoke to (V28 NP) about (R7). She agreed that the facility should have called when they noticed the foul smell and necrotic tissue in his right hip wound. It indicates a possible infection and given his history of sepsis; we would have had him sent to the ER for evaluation instead of waiting the next day for his appointment. I looked at his medical record he's currently in the ICU for septic shock. He shouldn't have waited for his appointment here. He should have gotten immediate treatment when they identified the infection. R7's hospital medical record dated 2/14/23 documents R7 was admitted to the intensive care unit for septic shock and pressure injury of contiguous region involving right buttock and hip, stage IV. 2. On 2/14/23 at 10:20 AM, R18 was lying in bed on her back and stated I have a sore near my tailbone that is very painful. They just gave me some medicine so hopefully will be better soon. 02/15/23 at 11:15 AM V3 (ADON/Wound Nurse) stated she is not aware of any pressure ulcers to R18's bottom and R18 is not on her list of wounds to assess weekly. On 2/15/22 at 11:22 AM, V24 (Certified Nursing Assistant/CNA) and V3 assisted R18 onto her left side, removed R18's incontinence brief and revealed an open area to R18's coccyx area that did not have any ointment or dressing over it. V3 stated the wound is an open stage II pressure ulcer and measures 1.0 cm (centimeters) by 0.2 cm with depth of 0.2 cm. V3 stated she was unaware of R18's pressure ulcer and the staff should have notified her at the time they found it. V3 stated she would call R18's doctor and get a treatment order. On 2/15/23 at 11:35 AM, V2 (Director of Nurses/DON) stated she spoke with the nurse who took care of R18 yesterday and said the nurse saw the area and notified hospice yesterday but forgot to chart it. On 2/15/23 at 12:02 PM V26 (Hospice Registered Nurse), stated she was at the facility on the morning of 2/14/23 and R18 had complained to her about her bottom being sore and when (V26) asked the nurse about it the nurse said it was only a small shearing area. V26 stated she asked the nurse specifically if the area was a pressure ulcer and the nurse said no. V26 stated no one called her about a pressure ulcer on R18's bottom. On 2/15/23 at 12:45 PM, V25 (Licensed Practical Nurse/LPN), stated she was the nurse for R18 on 2/14/23 and only saw a friction/shearing area to R18's sacrum that measured about 2 cm. V25 stated the area was only red at the time and was not open. V25 stated she did not call R18's family or R18's Physician and probably should have. V25 stated she thought V26 (Hospice RN) would notify the family. The Progress Note for R18, dated 2/14/23 at 1:00 pm, documents During cares patient observed to have skin shearing/red in color, area to coccyx. Area was not open. No drainage or warmth to area. Hospice nurse was at facility at the time, and it was reported. Hospice nurse stated we may use topical cream or zinc to area daily and prn until resolved. Zinc cream was applied to area at this time. The Physician Order Summary, dated 2/15/23, does not include any pressure ulcer treatment orders for R18.