**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews and policy review, the facility failed to ensure pain management was provided to resident who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 (#16) out of 5 (#15, #16, #22, #40, and #44) sampled residents receiving pain medication. The facility failed to: 1. provide pain medication upon complaints of pain nor offer non-pharmacologic interventions; and 2. follow up with the physician and/or pharmacy after the physician reported he was sending a pain medication order to the pharmacy. This deficient practice resulted in actual harm for Resident #16 beginning on 07/14/2024 at 10:02 a.m. when the resident reported she was in pain was not provided any medication nor offered non-pharmacological interventions for pain relief. On 07/15/2024, S6LPN (Licensed Practical Nurse) called S15DR to report the resident's pain and stated that he would send something to the pharmacy as soon as possible, however, no order was received by the pharmacy. On 07/16/2024 at 10:37 a.m., Resident #16 refused Physical Therapy because of continued pain and was not provided any pain relieving medication nor offered non-pharmacological interventions. On 07/17/2024 at 9:08 a.m., Resident #16 stated I am tired of hurting and the doctor still hasn't sent anything stronger than Tylenol to help with my back pain. The resident was sent to the ER (Emergency Room) on 07/17/2024 at 9:41 a.m. for low back pain. Findings: On 07/17/2024, a review of the facility's policy titled Pain Management with a last reviewed date of 01/2024 read in part, Policy: The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Policy Explanation and Compliance Guidelines: The facility will utilize a systematic approach for recognition, assessment, treatment and monitoring of pain. Recognition: 1. In order to help a resident attain or maintain his/her highest practicable level of physical, mental and psychosocial well-being and to prevent or manage pain, the facility will: . c. Manage or prevent pain . 2. Facility staff will observe for nonverbal indicators which may indicate the presence of pain. These indicators include but are not limited to: . d. Facial expressions (e.g. grimacing .) Pain Management and Treatment: 1. Based upon evaluation, the facility in collaboration with the attending physician/prescriber . prevent or manage each individual resident's pain . 6. Non-pharmacological interventions . 7. H. Facility will notify the practitioner, if the resident's pain is not controlled by the current treatment regimen . Review of Resident #16's health record revealed that she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Pain, Idiopathic Peripheral Autonomic Neuropathy, Transient Cerebral Ischemic Attack, Neurologic Neglect Syndrome and Chronic Pain Due To Trauma. Review of Resident #16's most recent Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating her cognition was intact. Section J Health Conditions: A. Received scheduled pain medication regimen? Coded 0. No. Review of Resident #16's physician's orders revealed an order dated 07/10/2024 that read in part, . PT (Physical Therapy) to tx (treat) 3 times a week for 8 weeks . Further review of orders revealed an order dated 04/13/2024 that read, Tylenol Extra Strength Oral Tablet 500 mg (milligram) (Acetaminophen) Give 2 tablets by mouth every 6 hours as needed for pain. Review of Resident #16's comprehensive care plan with a focus that read in part, The resident has a potential for pain r/t (related to): chronic physical disability . neurologic neglect . neuropathy with a goal that read, the resident will not have an interruption in normal activities d/t (due to) pain . with interventions that read in part, administer analgesia medications as ordered/requested, anticipate the residents need for pain relief and respond immediately to any complaint of pain, attempt non pharmacological pain relief techniques . document technique and effectiveness, observe and report changes in . sleep patterns Review of Resident #18's form titled Weights and Vitals Summary read in part, pain level documented on 07/14/2024 at 10:02 a.m. was rated a 5 out of 10 (pain scale from rated from 1-10 with 1 being the least and 10 being the most), further review revealed a pain level documented on 07/16/2024 at 10:37 a.m. was rated a 5 out of 10. Review of Resident #18's MAR (Medication Administration Record) from July 2024 failed to reveal administration of Tylenol Extra Strength Oral Tablet 500 mg on 07/14/2024 at 10:02 a.m. for pain rated 5 out of 10, and before this she was last given Tylenol on 07/13/2024 at 7:20 p.m. On 07/16/2024 at 10:37 a.m. when the resident reported pain rated 5 out 10 Tylenol was not administered, and before this was last given Tylenol on 07/15/2024 at 4:10 a.m. Review of Resident #18's progress notes failed to reveal non-pharmacological interventions were provided on 07/14/2024 at 10:02 a.m. and 07/16/2024 at 10:37 a.m. when the resident reported pain. On 07/15/2024 9:48 a.m., an observation was made of Resident #16. She was lying sideways on the bed and facial grimacing was noted. Upon interview, she complained of pain rated as a 10 out of 10 to left sided sciatica radiating down her left leg. She stated she has been feeling this pain since last week and all that she has received from nursing was Prednisone (steroid). She stated that she has notified nursing staff that the Prednisone is not working and she needs something else to help with her pain. She stated she had not received anything else to help with her pain. Review of progress note by S6LPN dated 07/15/2024 at 4:25 p.m. read, S6LPN spoke to S15DR's (Physician) nurse. S15DR's nurse stated that she sent a note to S15DR concerning resident's back pain. S15DR stated he would be sending something to the pharmacy ASAP (as soon as possible). Don't go to hospital until she tries what S15DR is sending. Further review of progress notes failed to reveal any documentation that S6LPN nor any other facility staff followed-up with the pharmacy or S15DR when no new pain medication was received for Resident #16. On 07/17/2024 at 8:55 a.m., a follow-up observation was made of Resident #16. She was lying sideways on the bed with facial grimacing noted. On 07/17/2024 8:55 a.m., a second interview with Resident #16. She rated her pain as a 10 out of 10 (worst pain possible) to the left side of the back down her left leg stating it was sciatica pain. She stated she has been having this pain for over 1 week now. She stated she received Prednisone during the day and Tylenol at times but none of these medications have worked. She stated she notified nursing staff that the medications were not working. She further stated I've been begging for something for pain. Review of progress note by S10LPN dated 7/17/1024 at 9:08 a.m. read, Called to room by resident, states I am tired of hurting and the doctor still hasn't sent anything stronger than Tylenol to help with my back pain. Pain 6/10. Refused any pain medication intervention at this time .(ambulance) called for transportation .09:30 a.m. transported to (hospital) in stable condition. Review of Resident #16's form titled Transfer Form dated 07/17/2024 completed by S10LPN read in part, . reason for transfer: Resident . going to hospital ER (Emergency Room) for low back pain . On 07/17/24 at 9:19 a.m. an interview was conducted with S10LPN. S10LPN stated resident has been in pain for about 1 week now. She stated the resident went to S15DR's for a rash and back pain on 07/09/2024 she was told by S15DR it was sciatica pain and to take OTC (over the counter) medication such as Tylenol. S10LPN stated communication was sent to S15DR about resident requesting something else for pain besides Tylenol on 07/13/2024 at around 10:15 a.m., but she was unable to provide any documented evidence of that communication. S10LPN confirmed she did not follow up with S15DR about prescribing the resident something else for pain after she communicated with him on 07/13/2024. S10LPN stated she worked again on 07/14/2024. On 07/14/2024 she had not heard back from S15DR about Resident #16's request to prescribe something else for pain nor did she attempt to call S15DR again. She confirmed she could have followed up with S16MD (Medical Director) of Resident #16's request for stronger pain medication. S10LPN stated based off her documentation in the EHR (Electronic Health Record) the resident reported 5 out of 10 on 07/14/2024 and she did not administer Tylenol as ordered to her on that shift and she stated she did not offer Resident #16 Tylenol. Four attempts were made to contact S6LPN via phone on 07/17/2024 at 10:17 a.m., 10:36 a.m., 11:40 a.m., and 2:47 p.m. S6LPN failed to return any phone calls and was unable to be interviewed. Four attempts were made to contact S13LPN on 07/17/2024 at 10:21 a.m., 12:10 p.m., 1:21 p.m., and 2:46 p.m. S13LPN failed to return any phone calls and was unable to be interviewed. On 07/17/2024 at 11:42 a.m. an interview was conducted with S12LPN. S12LPN confirmed that Resident #16 was in pain last night and was given Tylenol. She stated Resident #16 didn't sleep well last night and slept off and on. S12LPN confirmed the resident had been complaining of sciatica pain since last week. She stated she had not reached out to S15DR regarding the resident's pain because other staff had already. She stated she had not received any other updates from S15DR or nursing staff in report regarding resident's pain medication. She stated she had no provided non-pharmacological pain relief interventions to the resident. On 07/17/2024 at 12:30 p.m., an interview with S19PM (Pharmacy Manager). S19PM stated he reviewed resident #16's medications from February 2024 to 07/17/2024 and there were no new orders of pain medication. On 07/17/2024 at 12:37 p.m., attempted to call S15DR (Physician) per his answering system his office is closed on Wednesday's. On 07/17/2024 3:41 p.m., an interview with S3RDON (Registered Nurse, Regional Director of Nursing). She stated On 07/09/2024 Resident #16 went to an appointment with S15DR, new orders were implemented for resident to start PT. Phone call interview was conducted at this time with S20TD (Therapy Director) and S3RDON. S20TD stated the first therapy evaluation for Resident #16 was done on 07/10/2024. S20TD stated Resident #16 was unable to participate in therapy on 07/16/2024 due to her verbalizing that she could not get out of bed due to pain. He communicated to S6LPN that resident refused therapy due to pain. The resident's documented pain levels were then reviewed with S3RDON. She confirmed on 07/14/2024 at 10:02 a.m. and 07/16/2024 at 10:37 a.m. Resident #16 rated her pain at a 5 out of 10 and no Tylenol was administered and non-pharmacological interventions were not done nor documented. S3RDON then reviewed S6LPN's progress note dated 07/15/2024 that stated she had called S15DR regarding the resident's request for more effective pain medication. S3RDON confirmed that there was no follow up completed by the nurse. S3RDON confirmed that the staff should have followed up regarding Resident #16's pain with S15DR or S16MD on 07/15/2024 and 07/16/2024 and staff did not. She confirmed Resident #16 was sent to the emergency room today due to her pain. Review of Discharge Hospital Records dated 07/17/2024 read in part, . diagnosis hip pain bilateral, sciatica of right side, neuropathy. Medications given: Decadron, Demerol, and Phenergan. Start taking: Flexeril (muscle relaxant) and Tramadol (opioid analgesic). Resident #16 returned to the facility on [DATE] at 03:11 p.m.