**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was recovering from a recent right hip fracture and whose Plan of Care indicated that he/she required the use of chair and bed alarms for safety, the Facility failed to ensure nursing staff consistently implemented and followed interventions identified in his/her Plan of Care while meeting his/her care needs. On 12/25/24, Certified Nurse Aide (CNA) #1 transferred Resident #1 into bed but did not attach the alarm box to the bed alarm sensor pad. Resident #1 was found lying on the floor complaining of right hip pain. Resident #1 was transferred to the Hospital Emergency Department (ED) for evaluation and was diagnosed with a new right non-displaced greater trochanter fracture (upper part of the femur) which was inoperable. Findings include: Review of the Facility's Policy, titled Interdisciplinary Care Planning, dated as revised April 2024, indicated the following: -the facility will assess and analyze each resident's individual needs and provide effective person-centered care that meets professional standards of quality; -the Interdisciplinary process is performed by qualified medical professionals drawing from nursing, rehabilitation, social service, activities, dietetics, medical, and other consultative staff as deemed appropriate to promote continuity of care and communication among staff; -the care plan process is not limited to developing a written plan but also addresses the ongoing execution of care, treatment, and services that includes resident goals that are reasonable and measurable. Review of the Facility's Policy, titled Guidelines for the Use of Position Change Alarms, dated September 2018, indicated the following: -it is the policy of the facility to promote each resident's quality of life, ensure the highest practicable level of functioning and well-being and implement interventions to reduce and decrease risk of falls; -a position change alarm is an alerting device intended to monitor a resident's movement and emits an audible signal when the resident moves a certain way; -position change alarms included bedside alarmed mats, alarms clipped to a resident's clothing, seatbelt alarms, infrared beam motion detectors, chair and bed sensor pads; -the position change alarm will be utilized when it is determined that the benefit of the alarm is greater than the risk and potential negative effect of using the alarm; -the individualized, resident-centered care plan and CNA Care Card will be updated to reflect this approach and the specific type of alarm to be utilized. Review of the report submitted by the Facility via Health Care Facility Reporting System (HCFRS) Report, dated 12/31/24, indicated that on 12/25/24 at approximately 6:45 P.M., a staff member notified the nurse that Resident #1 was on the floor in his/her room. The Report indicated that the nurse observed Resident #1 [on the floor] with his/her feet facing the foot of the bed, the bed alarm was not sounding, and he/she complained of right hip pain. The Report indicated that although the CNA (later identified as CNA #1) had a printed assignment sheet detailing Resident #1's safety interventions, which included a bed and chair alarm, the alarm was not attached. The Report indicated that the physician was notified and Resident #1 was transferred to the Hospital Emergency Department (ED) for evaluation and treatment. The Report further indicated that an x-ray of Resident #1's right hip revealed he/she had a nondisplaced right great trochanteric hip fracture that was non-operative. Resident #1 was admitted to the Facility in September 2024 diagnoses included: displaced fracture of base of neck of right femur, cerebral infarction, hemiplegia (complete paralysis on one side) and hemiparesis (muscle weakness or partial paralysis on one side of the body) affecting the right dominant side, type 2 diabetes mellitus, dementia, psychotic disturbance, mood disturbance and anxiety, unspecified macular degeneration, osteoporosis, osteoarthritis, atrial fibrillation and intervertebral disc degeneration. Review of Resident #1's Care Plan related to Fall Risk, dated 12/04/24, indicated that he/she required the use of a bed alarm while in bed and a chair alarm while in chair. Review of Resident #1's CNA Care Card, (reviewed and updated in conjunction with his/her plan of care), indicated that he/she required the use of a bed and chair alarm. Review of Resident #1's Significant Change Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #1 required maximal assistance of staff with transfers. Review of the Assignment Sheet provided to CNA #1 for Resident #1, dated 12/25/24, indicated that Resident #1 required the use of bed and chair alarms. During a telephone interview on 01/09/25 at 1:51 P.M., (which included review of his written witness statement), CNA #2 said that on 12/25//24, Resident #1's roommate yelled out for help and said that Resident #1 had fallen. CNA #2 said that he ran into Resident #1's room and saw him/her lying on the floor. CNA #2 said that he immediately called the nurse to notify her that Resident #1 was lying on the floor. CNA #2 said that Resident #1 required bed and chair alarms for safety and said that he was surprised that the bed alarm had not sounded. CNA #2 said that he noticed that the alarm box was still attached to Resident #1's wheelchair and that the alarm box needed to be moved to Resident #1's bed when he/she was transferred into bed. CNA #2 said that Resident #1's CNA Care Card also indicated that he/she required the use of bed and chair alarms. Review of a Nurse Progress Note, dated 12/25/24, (written by Nurse #1) indicated that Resident #1 was found lying on the floor beside the bed with his/her feet facing the foot of the bed, with facial grimacing noted. The Note indicated that the bed alarm was not sounding and that the alarm box was attached to alarm sensor pad on the wheelchair. The Note indicated that Resident #1 was transferred to the Hospital ED for evaluation. Review of the Hospital Discharge summary, dated [DATE], indicated that Resident #1 had previously underwent a right hip hemiarthroplasty (surgical procedure that replaces the femoral head of the hip joint) on 11/28/24 for a displaced right femoral neck fracture. The Summary indicated that on 12/25/24 Resident #1 was brought to the Hospital ED after an unwitnessed fall, complaining of right hip pain. The Summary indicated that x-rays were obtained of the right hip and revealed a new right nondisplaced right greater trochanter fracture that is non-operative. During an interview on 01/08/25 at 3:10 P.M., (which included review of her written witness statement), Nurse #1 said that on 12/25/24, CNA #2 called her into Resident #1's room and she found Resident #1 lying on the floor complaining of right hip pain. Nurse #1 said that Resident #1 had recently undergone surgical repair of his/her right hip and required the use of bed and chair alarms for safety. Nurse #1 said that she noticed that the bed alarm was not sounding and that the alarm box was not attached to the bed alarm sensor pad but was still attached to the wheelchair sensor pad. Nurse #1 said that the CNA who was assigned to Resident #1 (later identified as CNA #1) told her that she was unaware that Resident #1 required the use of bed and chair alarms for safety. Nurse #1 said that Resident #1's assignment sheet [which was provided to CNA #1 at the start of the shift] and CNA Care Card clearly indicated that he/she required bed and chair alarms for safety. During a telephone interview on 01/08/25 at 1:15 P.M., (which included review of her written witness statement), CNA #1 (Agency CNA) said that on 12/25/24 she was assigned to provide care to Resident #1 and that he/she asked her to be transferred into bed. CNA #1 said that she transferred Resident #1 from the wheelchair into bed and said that no alarm sounded when he/she got up from the wheelchair. CNA #1 said that she did not transfer the alarm box from the wheelchair sensor pad to Resident #1's bed sensor pad and said she was not aware that Resident #1 required bed and chair alarms for safety. CNA #1 said she had two other residents on her assignment that day who required the use of bed and chair alarms, but could not recall where she obtained that information. CNA #1 said that someone gave her a piece of paper at the beginning of the evening shift on 12/25/24, with a list of the residents on her assignment. CNA #1 said that she looked at the piece of paper but could not recall if the paper indicated if Resident #1 required bed and chair alarms for safety. CNA #1 said that she was unaware that Resident #1 had a CNA Care Card. CNA #1 said that no one told her that Resident #1 required the use of bed and chair alarms until after he/she fell out of bed. During a telephone interview on 01/09/25 at 2:44 P.M., CNA #3 (Senior CNA on Resident #1's unit) said that she worked the 7:00 A.M. to 3:00 P.M. shift on 12/25/24. CNA #3 said that it is the Facility's process for the Senior CNA to give a verbal report and do walking rounds with the next shift CNA's, CNA #3 said the process included reviewing the CNA Care Card and assignment sheet of each resident with the oncoming CNA, and identifying those residents who require the use of alarms, including bed and chair alarms. CNA #3 said that at the beginning of the shift, at approximately 3:00 P.M. on 12/25/24, she gave verbal report and did walking rounds with the 3:00 P.M. to 11:00 P.M. (evening) shift CNA's and reviewed the CNA Care Card, as well as the assignment sheets with each of them. CNA #3 said that she remembers specifically stating that Resident #1 required the use of bed and chair alarms when she gave report and again when she did walking rounds that day with the evening shift CNA's. During an interview on 01/08/25 at 3:26 P.M., the Director of Nurses (DON) said that Resident #1 required the use of bed and chair alarms. The DON said that Resident #1's CNA Care Card and Assignment Sheet clearly indicated that he/she required the use of both a bed and chair alarm. The DON said that CNA #1 was an experienced CNA, who had been educated and trained on the need to review the CNA Care Card and assignment sheet before caring for a resident. The DON said that CNA #1 should have moved the alarm box from the wheelchair sensor pad and attached it to the bed sensor pad when she transferred Resident #1 from the wheelchair into bed. The DON said that CNA #1 did not follow Resident #1's plan of care. On 01/08/25, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area(s) of concern as evidenced by: A. On 12/25/24, Resident #1 was assessed by the nurse and transferred to the hospital for evaluation. B. On 12/25/24, Nurse #1 re-educated CNA #1 on the need to review the CNA Care Card and CNA Assignment Sheet for care directives prior to caring for a resident. Nurse #1 also reviewed Resident #1's CNA Care Card with CNA #1 that clearly indicated that he/she required the use of bed and chair alarms. C. On 12/25/24, Nurse #1 re-educated the staff on alarm boxes and the proper placement of alarm boxes. D. On 12/26/24, a full house audit was conducted by the DON and Unit Managers of all residents who utilize any kind of alarm to ensure that all of the components, alarm box, bed sensor pad and chair sensor pads were in working condition. E. On 12/26/24, the Charge Nurses re-educated Licensed Nursing Staff and CNA's on alarms to ensure that they are plugged into the box and functioning and to utilize the reset button instead of turning off the alarm when transferring residents. F. On 12/26/24, the DON initiated a Quality Assurance Performance Improvement Plan (QAPI) on ensuring that all alarms are functioning properly, to decrease the number of alarms and falls, increase evening activities and weekly alarm audits with the Unit Managers, Nursing Supervisors, Staff Development Coordinator and Charge Nurses. G. On 12/26/24, Resident #1's Care Plan and CNA Care Card were updated to include that he/she had separate alarm boxes for the bed and chair alarms and to keep frequently used items in close proximity to him/her. H. On 12/28/24, the Staff Development Coordinator re-educated Licensed Nursing Staff and CNA's on updating CNA Care Cards, that CNA's are required to review each residents Care Cards prior to providing care so they are aware of the resident's specific plan of care including safety interventions, adaptive equipment and Fall Prevention. I. On 01/03/25, the Senior CNA began weekly audits of all residents with alarms to ensure they have the correct alarms, the alarms are functioning and attached to the correct sensor pad, that all components are present and functioning. Audits will continue to be conducted weekly, as instructed by nursing. J. On 01/06/25, the Staff Development Coordinator re-educated Licensed Nursing Staff and CNA's on alarms and that they need to be checked at the start of each shift during walking rounds, check alarms for placement, function and to report any issues to the Nurse. K. Unit Managers and/or their Designee will conduct weekly audits x 90 days, on all residents with alarms to ensure that they are functioning properly, that all the components are present, the bed and chair sensors, and that the alarm box is not set to the OFF mode but set to the RESET mode. L. The results of the audits will be forwarded to the DON and Administrator, and will be brought to QAPI meeting quarterly x 3 or until the committee determines compliance. M. The Director of Nursing and/or Designee are responsible for overall compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observations, record review and interviews, the facility: 1) Failed to implement their policy for pain control; 2) Failed to develop an effective pain management regimen using both pharmacological and non-pharmacological interventions; 3. Failed to perform ongoing re-assessments of the current pain management program until optimal pain management is attained; and 4) Failed to utilize the program Around the Clock dosing administering analgesics regularly (not as needed), if pain is present most of the day to prevent ongoing break through pain for one Resident (#85) who sustained multiple pelvic fractures in a fall, out of total sample of 20 residents. Findings include: Resident #85 was admitted to the facility in May 2021 with diagnoses which included: stroke affecting the right side, cognitive communication deficit, dysphasia, anxiety disorder, dementia with behavioral disturbances, and Alzheimer's disease. Resident #85 also had an added diagnosis of multiple pelvic fractures following a significant fall out of bed in July 2021. Review of the most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 99, which indicated the Resident was unable to complete the assessment. In addition, the MDS indicated, the Resident received scheduled and as need pain medication, but no non-medication interventions were in place. Review of the facility's policy titled Pain Management, dated February 2016, indicated the following: -It is the policy of the facility to assess the acute and chronic pain needs of each resident prior to and post administration of physician ordered pain medication and to develop an effective pain management regimen that will address the pharmacological and non-pharmacological interventions that will effectively meet those needs. -The goal is to promote prompt and effective assessment, diagnosis and treatment of a resident's experience of pain or discomfort. -The pain flow sheet (back of the MAR) will be used to document the resident's level of pain prior to administration of the medication and to document the effectiveness of the as needed medication 15-30 minutes after administration. The documentation should reflect the numerical pain management scale or the Wong-Baker or dementia scales. -The effectiveness of the resident's pain management regimen including scheduled pain medication will be assessed on an on-going basis utilizing the resident's response to pain management, in order to determine whether to continue the current protocol or to modify the program. Re-assessment for effectiveness will be made as indicated until optimum pain relief has been attained using the least amount of medication and incorporation of non-pharmacological interventions. -Physical therapy and Occupational Therapy will also assess the residents as necessary to determine if there are appropriate interventions that may enhance the effectiveness of the program. Guidelines for Assessing Pain: -To provide a preventive approach to analgesia, such as pain management should occur before the onset of pain or before pain increases. -To use Around the Clock (ATC) dosing in an attempt to manage chronic and acute pain. -Administer analgesics regularly (not PRN) if pain is present most of the day. -Analgesics should be administered initially on a regular basis and frequency should be adjusted to prevent pain from recurring. Interruption of Around the Clock dosage schedule may cause a resurgence of pain as blood level of the analgesic decline. -Give analgesics on a regular schedule to prevent a loss of effectiveness between doses. Pain in non-verbal residents or those with impaired communication: -Systematically observe possible pain and comfort behaviors related to vocalizations, facial expressions, body movements, behavior/activity change and autonomic responses. Pain Assessment in the Confused Elderly: -Reports from the family or caregiver. -Rubbing body parts. -Change in vocalization. Effects of Pain: -Discomfort, suffering -Sleep disturbances -Anxiety, fear -Irritability -Poor quality of life Review of Resident #85's CT scan, dated 7/11/21, indicated the following: -Comminuted right acetabular (hip socket) fracture involving both the anterior (front) and posterior (back) columns with mildly displaced fracture segments. The fracture line extends into the lateral aspect of the right superior pubic ramus (front portion of the pelvic bone). -There is an additional minimally displaced fracture involving the medial aspect right superior pubic ramus. -There is a minimally displaced fracture involving the posterior aspect of the right inferior pubic ramus. -There is a minimally displaced, small focal fracture involving the anterior, mid to lower aspect of the right sacrum (triangular bone at the base of the lower spine). -There is a non-displaced fracture involving the upper coccyx (small triangular bone at the base of the sacrum). -Small amount of right periarticular soft tissue hematoma/hemorrhage (collection of blood) and intra pelvic hematoma/hemorrhage. Review of the physician's progress note, dated 7/13/21, indicated the following: Current medications: -Oxycodone 2.5 milligrams (mg) every four hours as needed -Trazodone 50 mg at bedtime Review of systems: - As I walked into the room, he/she appeared to be in pain. He/She did endorse moderate to severe pain. He/she has not asked for pain medications as discussed with nursing. Assessment and Plan: -Late onset Alzheimer's dementia with behavioral disturbances. -Scheduled Oxycodone 2.5 mg twice daily and will continue every four hours as needed. -Follow up with orthopedics on 7/15/21 Review of Resident #85's orthopedic consult, dated 7/15/21, indicated the following: -Right acetabular fracture minimally displaced -Plan: Non operative treatment, Non-weight-bearing, Bed to Chair, Follow up in five weeks Medications: -Oxycodone 5 mg immediate release tablets: Take 0.5- 1 tablet (2.5-5 mg total) by mouth every four hours as needed for severe pain (7-10.) Max daily amount 30 mg. -Trazodone 50 mg tablet: take 50 mg by mouth at bedtime as needed. Review of Nurse Practitioner's note, dated 7/29/21, indicated the following: -Resident #85 had recent pelvic fracture - Chief complaint: increased agitation yelling out? [Question] Pain. -Nursing reports he/she has increased agitation and is yelling out often. Question poor pain control. Plan: -Schedule Oxycodone 5 mg three times daily and every 4 hours for as needed pain. -Change Trazodone to twice daily as needed for anxiety Review of the nursing progress notes, dated 7/15/21 thru 7/29/21 indicated the following: -7/15/21 (04:00 A.M.) Patient calling help me, upon entering room patient reported pain 8/10 pelvic pain. Gave as needed (PRN) Oxycodone 5 mg given at 3:15 A.M. -7/15/21 (08:17 A.M.) Nurse Practitioner aware of increased pain. New order to increase Oxycodone to 5 mg twice a day. -7/15/21 (09:14 P.M.) Utilizing Oxycodone scheduled twice a day and PRN every four hours as needed -7/15/21 (03:17 P.M.) Complains right hip and pelvic pain 8/10 received PRN Oxycodone 2.5 mg. -7/15/21 (08:30 P.M.) Resident given APAP (acetaminophen) at 4:40 P.M. for complaints of pelvic pain 5/10 with fair effect. Resident yelling out help me and restless at 7:00 P.M., medicated with Oxycodone 2.5 mg and Trazodone PRN, repositioned, and total care given by staff with fair effect. -7/16/21 (03:47 P.M.) Tolerating out of bed 7:30 A.M. to 1:30 P.M. Gave PRN Oxycodone at 12:30 P.M. for signs and symptoms of grimacing and restlessness. -7/16/21 (09:05 P.M.) Lethargic afternoon Trazodone held. Gave PRN APAP 650 mg along with scheduled Oxycodone (2.5 mg due to lethargy) with good effect. -7/18/21 (08:50) Gave PRN Oxycodone 5 mg at 3:35 P.M., resident giving 7/10 pain scale medication had moderate effect. Became agitated in bed after receiving PRN pills, yelling out: redirection unsuccessful. -7/19/21 (06:49) Reclining chair used for comfort and safety to get resident out of bed. Gave PRN Oxycodone 5 mg given at 4:35 P.M., pain rated a 7/10 by resident, Oxycodone had moderate effect. Resident brought into the day room at 4:45 P.M. Resident exhibited increased yelling and agitation. Given scheduled Depakote early due to behavior, wheeled over to nurse's station 1:1. Tried to use the wall and turn Broda (reclining chair) chair towards the room: redirected unsuccessfully. Resident put back to bed at 7:00 P.M. Follow up by nurse at 8:00 P.M., resident sleeping and breathing evenly. At 9:45 P.M., resident calling out spouse's name, exhibiting increased agitation. Gave PRN Trazadone 50 mg for behavior at 9:51 P.M. -7/20/21 (07:40 P.M.) Gave PRN Oxycodone for pelvic pain 7/10, effective results noted. -7/20 (10:50 P.M.) Resident put to bed at 4:45 P.M., became agitated, yelling and attempting to self-transfer. Complained pain 7/10, gave Oxycodone 5 mg and APAP 650 mg for headache at 5:07 P.M., to moderate effect. -7/21/21 (10:48 P.M.) Resident complained of bilateral lower extremity pain at 4:00 P.M., gave PRN Oxycodone with moderate effect. Complained of anxiety at 5:00 P.M., gave PRN Trazodone with moderate effect. -7/22/21 (05:47 A.M.) Gave PRN Oxycodone 5 mg due to pelvic pain 7/10, positive effect. -7/22/21 (12:35 P.M.) Complained of left hip pain 7/10 at 12:00 P.M., gave PRN Oxycodone 5 mg with good effect. -7/22/21 (10:41 P.M.) Resident yelling out help at the start of shift, scheduled medications given with little effect. Resident yelling out a lot after dinner, Gave PRN Trazadone at 6:15 P.M., with some effect. PRN APAP given at 6:15 P.M. for temperature of 100.2. -7/23/21 (06:59 A.M.) Gave PRN Oxycodone for pelvic pain 7/10 during care. Resident yelling out help and facial grimacing noted. Positive effect noted. -7/23/21 (10:46 P.M.) Began to yell out after dinner, given PRN Trazadone and PRN Oxycodone 5 mg at 6:00 P.M., with poor effect. One-on-one with nurse after attempts to self-transfer and continued with verbal outburst. One-on-one had moderate effect on behavior. Resident given P.M. scheduled medications and put to bed. Resident resting comfortably, sleeping and even breathing. -7/24/21 (2:07 A.M.) Resident complained of bilateral lower extremity pain at 2:15 A.M., gave PRN Oxycodone with good effect. -7/24/21 (6:05 A.M.) Gave PRN Oxycodone for pelvic pain 7/10, Resident moaning and calling for help. -7/24/21 (9:10 P.M.) Resident began to yell out from bed, increased agitation, gave PRN Trazodone and Oxycodone 5 mg at 3:40 P.M. to moderate effect. Resident was transferred out of bed at 4:45 P.M. and ate dinner at the nurse's station. After dinner resident yelling out, redirection to little effect. Resident transferred back to bed and gave P.M. scheduled medications. -7/25/21 (2:25 P.M.) Gave PRN Oxycodone for 8/10 pelvic pain, resident yelling from room. Good effect noted. -7/25/21 (8:53 P.m.) Resident calling out from bed at start of the shift. Gave PRN Oxycodone at 3:30 P.M., 5 mg, to poor effect. Given scheduled Trazodone and Depakote. Transferred to wheelchair for dinner at 4:30 P.M., yelling/behavioral while sitting in wheelchair next to nurse's station. Given PRN Trazodone at 4:40 P.M. and APAP 650 mg at 5:00 P.M. Resident stayed out of bed until 6:45 P.M. At 9:45 P.M. given PRN Oxycodone 5 mg when resident began to call out wife's name, agitated in bed with facial grimacing and increased breathing. -7/26/21 (06:40 P.M.) Gave Oxycodone at 1:45 A.M. for yelling out Help me due pelvic pain. -7/26/21 (12:32 P.M.) At 10:00 A.M. gave resident PRN Trazodone for continually yelling out for help. -7/26/21 (10:56 P.M.) Resident up in wheelchair at 3:45 P.M. for dinner, gave PRN Oxycodone for discomfort, gave PRN APAP at 5:12 P.M. Agitated during dinner, yelling out. CNA provided 1:1, continued to be agitated. Resident put back to bed at 7:00 P.M. -7/26/21 (2:47 P.M.) Gave PRN Oxycodone for pelvic pain. Resident yelling out help me, unable to give number value, facial grimacing noted. Positive effect. -7/27/21 (10:11 P.M.) Gave PRN Oxycodone 5 mg at 3:10 P.M. to moderate effect. Agitated gave PRN APAP at 4:20 P.M. and PRN Trazodone at 5:10 P.M., both to moderate effect -7/28/21 (3:02 P.M.) Resident complained of pain all over, pain 8/10 gave scheduled Oxycodone 5 mg at 8:00 A.M. with good effect. Out of bed most of the shift. -7/28/21 (6:11 P.M.) Gave PRN Oxycodone 5 mg at 5:30 P.M. for increased pain and discomfort. Resident calling out and yelling. Unable to give numeric pain scale, answered yes when asked if in pain. -7/28/21 (10:00 P.M.) Resident sitting up at nurse's station from 7:00 P.M. to 10:00 P.M. due to safety issues. Resident with increased agitation, yelling help me multiple times. Scheduled Oxycodone administered with PRN APAP for pelvic pain 7/10, some effect noted. -7/29/21 (12:43 P.M.) Resident hollering out for help. Morning medications given out of bed for breakfast. Remained up until 9:00 A.M., then became restless. Resident back to bed until 11:15 A.M., then up for lunch. Resident remained up until 12 noon and then became restless once more. Resident said had pain in the legs and rated 8/10 on scale one to ten. Overt signs and symptoms of pain facial grimace and restless, trying to adjust position his/her position. Gave PRN Oxycodone at noon and placed in bed at 12:45 P.M. -7/29/21 (05:39 P.M.) At start of shift resident complained of increased pain, yelling out and grabbing right leg, medicated with Oxycodone 2.5 mg at 3:30 P.M. and repositioned with no effect noted, at 4:20 P.M. resident continues to yell out, medicated with PRN Oxycodone 5 mg for severe pain and Trazodone 50 mg for increased anxiety with fair effect. -7/29 ( 5:31 P.M.) Nurse Practitioner in today, new orders to change Oxycodone to 5 mg three times a day and Oxycodone 5 mg PRN every four hours for pain. Review of the Medication Administration Record (MAR) from 7/15/21-7/29/21 indicated Resident #85 received all scheduled Oxycodone 5.0 mg twice a day at 8:30 A.M. and 8:00 P.M. Review of the MAR from 7/15/21-7/29/21 indicated Resident #85 received as needed Oxycodone 5.0 mg pain medication 31 times in 15 days with the following Resident complaints of pain rated or described. 7/10- 12 times 8/10- 8 times 9/10 - 3 times 10/10 - 1 time severe- 1 time Facial grimacing- 6 times Review of the MAR from 7/15/21-7/29/21 indicated Resident #85 received as needed Oxycodone 2.5 mg pain medication 6 times in 15 days with the following Resident complaints of pain rated or described: 6/10 - 3 times 7/10 - 1 time 8/10 - 1 time Pain, yelling out- 1 time Review of Interdisciplinary Resident Data Collection provided by the Rehabilitation Director indicated the following: -7/12/21-Functional change noted, recent fall with multiple pelvic fractures. Rehabilitation comments: Status post fall with pelvic fractures, made non-weight-bearing. Nursing advised to use mechanical lift to transfer or remain in bed. Orthopedic follow up made for 7/15/21 and will follow up then for any changes. --7/16/21-Rehabilitation follow up to orthopedic visit. Rehabilitation comments: Resident returned from orthopedic with orders for non-weight-bearing and transfers only. Bed to chair. Due to resident's cognitive status, he/she is unable to trial physical therapy and comply with weight-bearing. Educated nursing to continue to use mechanical lift until weight-bearing is upgraded. Review of Pain Assessment, dated 7/13/21, indicated the following: -Been on scheduled pain medication regimen-No -Received as needed (PRN) pain medication- Yes -Received non-medication intervention for pain- No -Resident unable to answer specific pain questions -Indicators of pain or possible pain in the last five days: Non-verbal sounds (crying, whining, gasping, moaning or groaning) and vocal complaints of pain (that hurts, ouch, stop). Evaluation: Resident denies pain. Displays pain with movement by yelling out or moaning loudly. PRN Oxycodone in place. On 07/27/21 at 04:30 P.M., the surveyor observed Resident #85 sitting in a standard wheelchair and appeared to be in pain and having difficulty weight shifting. The left leg rest was elevated higher than the right leg rest, keeping the left hip flexed greater than 90 degrees. During an interview on 07/27/21 at 4:45 P.M., Resident #85 said he/she was in pain and pointed to the left hip area. Resident #85 was observed yelling out for help and attempting to pull his/her pants away from the left hip. During an interview on 07/29/21 at 11:00 A.M., Resident #85 said he/she was feeling a little better but was still having stomach pain. Resident #85 was observed lying on the right side in bed, with his/her left hand across the lower stomach, rubbing back and forth. During an interview on 07/29/21 at 02:37 P.M., Nurse #9 said they changed Resident #85's pain medication today from scheduled twice a day to scheduled three times a day and added as needed (PRN) Trazodone 50 mg. Nurse #9 said the reason Trazodone was increased was because the Resident was having increased agitation and anxiety. Unit Manager #2 said the only pain interventions in place for Resident #85 was scheduled and as needed Oxycodone for pain and Trazodone for anxiety. On 07/29/21 at 04:32 P.M., the surveyor observed Resident #85 sitting in a standard wheelchair in the dining room yelling out in pain and requesting to go to bed. The Certified Nursing Assistant (CNA) was heard by the surveyor, telling Resident #85 he/she could not go to bed and had to stay up for dinner. The CNA offered Resident #85 a drink and brought him/her to the nurse's station. Resident #85 was observed to have his/her left hand across the lower stomach in his/her pants, continued to attempt to weight shift and yelling out for help. During an interview on 07/29/21 at 04:32 P.M., Nurse #10 said Resident #85 having his/her hand in the pants was a gender thing. Nurse #10 said she gave Resident #85 an Oxycodone at 3:30 P.M., and it was ineffective, so now she can give him/her another PRN Trazodone. Nurse #10 said the Trazodone was for anxiety, because if Resident #85 is anxious he/she won't eat dinner. During an interview on 07/30/21 at 04:02 P.M., the Rehabilitation (Rehab) Manager said Resident #85 was only referred for a rehab or screened on 7/12 after returning from the hospital and on 7/16 after seeing the orthopedic physician to assess Resident #85's transfer status. The Rehab manager said she had recommended in one morning meeting (No date provided), shortly after the fractures, that Resident #85 could benefit from a reclining chair due to the fractures, which would allow the Resident #85 to recline back and off-weight the multiple fractures. The Rehab Manager said nursing told her Resident #85 was tolerating the standard wheelchair well. The Rehab Manager said no other interventions were put into place for pain management by the Rehab department between 7/15/21-7/29/21. On 07/30/21 at 01:45 P.M., the surveyor observed Resident #85 being wheeled back to the unit by a staff member and left in the dining room. Resident #85's Spouse was following and was visibly upset and crying. Resident #85 was yelling out in pain and had facial grimacing. Resident #85's spouse requested to speak to a nurse. A CNA (unidentified), then wheeled Resident #85 back to his/her room to wait for a nurse. The surveyor observed Resident #85 and the spouse sitting in the room. Resident #85 continued to yell out for help and his/her spouse was sitting in the chair crying. During an interview on 07/30/21 01:50 P.M., Resident #85's Spouse was crying and visibly upset. The Spouse said, I don't know what to do, he/she is getting worse. Resident #85's Spouse said the nurse called him/her last night and said they were increasing Resident #85's pain medication and the Spouse thought he/she would be better today. Resident #85's Spouse said he/she is not better; he/she is worse. Resident #85's Spouse said, The whole time I have been visiting today he/she was screaming out in pain. During the interview, Resident #85 kept yelling out please help me, I don't feel good, please help. The Resident had the left hand in his/her pants rubbing the lower stomach. Resident #85's spouse said he/she does not normally have his/her hand in the pants, rubbing the stomach. The surveyor went to the nurse's station and asked for assistance for Resident #85 and the Unit Manager #2 said his/her nurse was on break, but she could help. Review of Resident #85's medical record indicated there was no further comprehensive Pain Assessment performed after 7/13/21. During an interview on 07/30/21 02:25 P.M., Unit Manager #2 said they manage Resident #85's pain with pain medication and the Resident is non-weight-bearing. She said the staff gets Resident #85 up for breakfast and as soon as he/she exhibits signs of anxiety, they put him back to bed. Unit Manager #2 said Resident #85 had to stay up for dinner on 7/29/21, because he/she is out of bed for all meals. During an interview on 07/30/21 02:45 P.M., Resident #85's Spouse said he/she is comfortable now, he/she just can't sit that long. Resident #85's Spouse said, I just don't know what to do, he/she is getting worse instead of better, I wanted to take him/her home, but now I don't know. During an interview on 07/30/21 at 02:55 P.M., the Director of Nurses (DON) said Resident #85 does not have to stay up for dinner if he/she is in pain. She said a staff member could feed him in bed. During a phone interview on 8/4/2021 at 11:50 A.M., the Nurse Practitioner (NP) said she just saw Resident #85 at the request of nursing staff due to increased pain and agitation. She said the Resident's scheduled pain medication was increased from twice a day to three times for more consistent pain coverage, especially because he/she does not ask for pain medication. NP said, she last addressed Resident #85's pain on 7/15/21 and is in the facility two times a week and would expect the nursing staff to inform her if Resident #85's pain was not well controlled. NP said she would not consider pain well controlled if the resident was having pain 7/10 or above consistently between the dates of 7/15/21-7/29/21.