**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 22 residents with 10 residents sampled and one resident reviewed for pain management and two additional residents reviewed for unnecessary medication use. Based on observation, interview, and record review the facility failed to assess pain and failed to take appropriate action to manage severe pain despite repeated complaints from Resident (R)74. Additionally, the facility lacked effective communication between nurses, doctors, and other healthcare providers regarding R74's pain management. This failure led to R74 reporting waves of severe pain over approximately a month, until her death on [DATE], and placed R74 in immediate jeopardy. Findings Included: - Review of the Electronic Health Record (EHR), documented R74 had diagnoses of incisional hernia (occurs when the abdominal muscles or connective tissue weaken or gap at the site of a surgical incision, allowing abdominal contents to protrude. This can happen weeks, months, or years after the surgery) and osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain). The [DATE] Quarterly Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderately impaired cognition. R74 was independent with transfers and bed mobility, she required set up for oral care and eating. R74 required supervision for ambulation, dressing, toileting, personal hygiene, footwear, and maximum assistance required for bathing. The resident reported her pain at a level 5 out of 10, that occurred occasionally and affected her sleep. The [DATE] Annual MDS lacked a BIMS score and lacked a staff interview; cognition was not assessed. Depression was not assessed. R74 required maximal assistance with activities of daily living (ADL) such as bathing and bed mobility. She required supervision assistance with ambulation, toileting, dressing, personal hygiene, and footwear. R74 rated her pain at a six out of 10, which occasionally affected her sleep. The [DATE] Cognitive Loss/Dementia CAA documented R74 triggered for cognitive loss related to rejection of care on occasion. The [DATE] Pain CAA triggered related to R74 had occasional pain. The resident's Care Plan documented the following: [DATE] - Staff were instructed to recognize the resident's pain tolerance and her level of discomfort as real and painful for her. [DATE] - Staff were instructed to use alternative methods for pain management such as massage, aroma therapy, warm packs, and distraction. [DATE] - Staff were educated to monitor for nonverbal cues of pain such as facial grimace, guarding, and moaning. Review of the Physician Orders documented the following: Acetaminophen 325 milligram (mg) tablet, give two tablets by mouth, every six hours as needed for pain, date ordered [DATE]. Acetaminophen 325 mg tablet, give two tablets by mouth, three times a day for moderate pain, date ordered [DATE]. Review of the Medication Administration Record dated [DATE] thru [DATE] documented staff administered R74's Acetaminophen on the following days: On [DATE] at 11:25 PM, reported pain level of five, with effective results noted. On [DATE] at 11:20 PM, reported pain level of five, with effective results noted. On [DATE] at 11:31 AM, reported pain level of four, with undetermined results noted. On [DATE] at 05:52 AM, reported pain level of seven, with ineffective results noted. On [DATE] at 02:46 AM, reported pain level of six, with ineffective results noted. On [DATE] at 04:11 AM, reported pain level of eight, with ineffective results noted. The [DATE] at 03:51 PM Progress Note revealed R74 complained of stomach discomfort. The on-call provider was notified and gave and order for Simethicone (medication used to relieve the painful symptoms of too much gas in the stomach and intestines) 80 mg three times, daily. The [DATE] at 11:23 PM Progress Note revealed R74 reported abdominal pain at a level of six out of 10 for last three days. R74 experienced polyuria (is when your body makes too much urine) more than baseline. R74 requested assistance to the bathroom multiple times an hour on top of having multiple incontinent episodes. R74 was very restless and unable to rest for more than 15 to 20 minutes without yelling out or pressing her call light. Urinalysis (lab analysis of urine) was to be collected on [DATE] in the morning when the lab was open. The [DATE] at12:09 PM Progress Note revealed R74 complained frequently to several staff that her stomach hurt. R74's blood pressure was elevated to 204/100 millimeters of mercury (mmHg) and staff administered an as needed dose of clonidine (medication for high blood pressure). The writer informed the provider via the telephone at 11:30 AM regarding the resident's elevated blood pressure and complaint of stomach pain. The provider did not give any new orders to address the resident's complaints of pain. The [DATE] at 08:35 AM Progress Note revealed staff sent a communication to R74 's provider regarding her continued complaints of abdominal discomfort and new complaints of nausea, confusion, dizziness, and the shakes. The provider gave an order to obtain a urinalysis and give four mg of Zofran (is a medication that prevents nausea and vomiting). The note lacked evidence the provider addressed the resident's pain. The [DATE] at 11:32 AM Progress Note revealed a communication was sent to the resident's provider, R74 continued to not feel well, the facility received orders for R74 to have a computed tomography (CT scan- test that used x-ray technology to make multiple cross-sectional views of organs, bone, soft tissue and blood vessels) and outpatient labs. The [DATE] at 04:59 PM Progress Note revealed R74 had a partially strangulated hernia (occurs when the blood supply to the herniated (an abnormal condition or process in which an organ or other tissue protrudes through an opening tissue) has been decreased in flow) and she was sent to the hospital per provider. The [DATE] at 08:32 PM Progress Note revealed R74 returned from the hospital with no new orders. The resident had no complaints of pain upon her return. Review of the resident's record from [DATE] through [DATE] lacked any follow up progress notes after R74's hospital visit. The [DATE] at 02:53 AM Progress Note revealed staff found R74 on the floor with no injuries noted. The [DATE] at 11:44 PM Progress Note R74 used her call light up to 30 times in an hour. R74 continued to call out help me God, help me up. I cannot do those things R74 was very restless, and as needed acetaminophen was utilized multiple times, but the resident had no changes in behaviors. R74 yelled at staff for the past two days when staff attempted to help her. R74's confusion and anger increased, and her urinalysis came back negative. R74 screamed No when transferred to the wheelchair. Staff sent a fax to the resident's provider to please advise. The [DATE] at 09:01 AM Progress Note revealed R74 up was up and self-propelled around in her wheelchair with no complaints of pain expressed. The [DATE] at 03:20 PM Progress Note revealed R74 was found on the floor in her room with no injuries noted. R74 repeatedly stated God help me and she had no complaints of pain associated with fall. The [DATE] at 11:43 PM Progress Note revealed R74 continued to be very restless, would lay down in bed, and yell God help me, God help me up. When R74 was assisted up to a wheelchair R74 would continue to yell God help me, I need to lay down. R74 could not be redirected and continued to push her call light when staff was in the room. Day shift reported R74 exhibited the same behaviors, and staff administered as needed acetaminophen multiple times. The resident had no changes in behavior or relief noted. The writer noted multiple faxes were sent to the resident's provider. The [DATE] at 01:19 PM Progress Note revealed R74 was seen by the provider, noted R74 wanted to go home, and the provider ordered a urinalysis. The [DATE] at 02:22 PM Progress Note revealed R74 was not herself, she was lethargic, incontinent with loose stools, had a temperature of 98.0 degrees Fahrenheit, a pulse of 58 beats per minute, respirations at16, blood pressure measured 92/37 (low) and oxygen saturations (percentage of oxygen in the blood) was 93% on room air. R74 was slightly pale in color and her provider was notified of a suspicion of sepsis. Labs were ordered and a chest Xray if wheezing or cough was noted. Labs were obtained and sent to lab for processing. The [DATE] at 05:09 PM Progress Note revealed lab results were received and reported to the resident's provider. New orders were given to change the resident's antibiotic to Bactrim DS twice a day for seven days and the order for Macrobid (antibiotic) was discontinued. The [DATE] at 02:33 AM Progress Note revealed R74 required three staff members to transfer her to the wheelchair as R74 was unable to assist. R74 was hunched over in her wheelchair and could not sit up erect. R74 was assisted to the toilet and was unable to stand once at the toilet, R74 leaned over sideways, and her upper body leaned up against the wall as she began to have dry heaves. R74 was assisted back to bed after she received care. R74 yelled and moaned the entire time. R74 responded that she had pain in her back. The resident's vital signs were out of limits, R74's respiration's fluctuated from 18 to 28 breaths per minute, her oxygen saturation was 86%- to91% on room air and R74 laid in her bed with her eyes closed. Review of the [DATE] Hospital Visit documentation confirmed the resident went to the hospital, the EHR lacked evidence of the residents transfer to the hospital. The hospital paperwork in R74's paper chart documented R74 was there for a little over an hour and all of her medications were discontinued except for Acetaminophen and Bactrim DS. The facility was to consult hospice for R74 for anemia (inadequate number of healthy red blood cells to carry adequate oxygen to body tissues) and gastrointestinal bleeding (bleeding into the stomach and/or digestive tract). R74's full code was changed to a do not resuscitate (DNR- or no code, a legal document or order that means the person does not desire CPR in the event of cardiac arrest). The [DATE] 09:17 AM Progress Note revealed R74 had her eyes open and made eye contact when spoken to. The [DATE] at 10:21 AM Progress Note revealed R74 passed away at 09:56 AM. The [DATE] at 10:29 AM Discharge Note revealed Hospice services were ordered, but not completed before R74 passed away. All medications were discontinued during the hospital visit during the night except for Acetaminophen and Bactrim DS. During an interview on [DATE] at 02:12 PM, Certified Nurse Aide (CNA) M reported if a resident complained of pain, staff were to notify the charge nurse. CNA M could not recall R74 complaining of pain, she did report R74 would sometimes yell out for help. During an interview on [DATE] at 01:37 PM Administrative Nurse B reported R74 received an order for hospice services when she transferred back from the hospital on [DATE] but she passed away prior to hospice consult being completed. Administrative Nurse B reported R74 could not have anything stronger than Acetaminophen for pain, when Administrative Nurse B was asked why, she could not recall why she could not have a stronger pain medication. Additionally, Administrative Nurse B reported she was instructed on what she could and could not chart in the resident's progress notes. When Administrative Nurse B was asked what kind of notes that she could not document, she commented They are old and are going to die anyways that is what was said to her when some of the providers were contacted for residents' concerns. Administrative Nurse B did not identify which provided stated that. Additionally, she reported she could not jump over the providers heads and call the medical director as the on-call providers would get mad. Administrative Nurse B confirmed that R74's progress notes lacked abdominal assessments and follow through with complaints that R74 had with her pain. During an interview on [DATE] at 02:45 PM, Licensed Nurse (LN) G reported if a resident did not have relief from a scheduled or as needed pain medication, the provider should be notified and updated on resident's condition and should receive new orders. LN G reported that there were some residents that would drug seek for pain medications so they may not receive new orders. The facility policy Pain Management dated 10/2022 documented to provide a systematic approach for identifying residents at risk for pain and develop interventions to decrease the effect of pain on the resident's quality of life. To provide guidelines for assessment and individualized treatment plan including pharmacological and non-pharmacological interventions. The facility is to review all residents with unmanaged pain weekly. If there is a decline in the effectiveness of pain management, the plan of care is to be reviewed for appropriateness and revised as needed. The physician and responsible party are to be notified of the need to changed pain management interventions and plan of care. The facility failed to assess pain and failed to take appropriate action to manage severe pain despite repeated complaints from Resident (R) 74. Additionally, the facility lacked communication between nurses, doctors, and other healthcare providers regarding R74's pain management. This failure placed R74 in immediate jeopardy. On [DATE] at 10:25 AM, Administrative Staff A and Consultant Staff T were provided the Immediate Jeopardy (IJ) template and notified the facility failure to ensure staff identified, updated providers and responded appropriately to complaints of R74's pain that was consistently left without an effective pain medication being administered, leading to signs of distress, such as moaning, yelling and agitation which significantly impacts their quality of life and could potentially result in further complications if not addressed and R74's unrelieved pain could be a possible indicator of a returned strangulated hernia or other significant disease processes. The facility submitted an acceptable plan for removal of the immediate jeopardy on [DATE] at 02:35 PM which included the following: 1. R74 died on [DATE]. Residents will have a pain assessment including assessment of areas identified completed with physician intervention if appropriate and the care plan updated on [DATE]. 2. Pain assessed every shift by licensing nursing with staff interventions if applicable date started [DATE]. 3. Immediate Quality Assurance and Performance Improvement (QAPI is a data-driven approach to improving the quality of care and services provided to patients) meeting held with the Medical Director, Administrative Staff A and Administrative Nurse B completed on [DATE]. 4. License staff will receive education on pain assessment including assessment of areas identified with pharmacological and non-pharmacological interventions and verbal notification on [DATE]. 5. Administrative Nurse B or designee will audit pain goals and reported pain with interventions through clinical excellence on [DATE] 6. Physician and responsible party are to be notified and documentation of the need to change pain management interventions and plan of care on [DATE] 7. Results of audits findings will be reviewed during QAPI meeting monthly. The surveyor verified the above corrective actions were implemented while on-site on [DATE]. This deficient practice remained at a scope and severity of a G.