**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intakes MI00145596 and MI00145720. Based on interview and record review the facility failed to ensure scheduled and as needed pain medications were administered per the physician's orders for one (R103) of three residents reviewed for pain management resulting in uncontrolled pain, frustration, anger, and feelings of helplessness. Findings include: On 11/6/24 at 11:57 a.m. the complainant (R103) was contacted and spoken to about the allegations submitted to the state agency complaint hotline on 7/11/24. The complainant said the complaint was made because of multiple daily calls from R103 not getting pain medication ((R103) would literally be in tears begging me to come get him because he was in so much pain. (R103) called me the first night he was there crying because he couldn't get his pain pill. Nobody would answer the call bell.) The complainant also said R103 left the facility due to not receiving decent medical care. Nurse progress note dated 8/20/24 documented R103 left the facility against medical advice. Review of the clinical record documented R103 was admitted into the facility on 7/3/24 and discharged on 8/20/24 with diagnoses that included malignant neoplasm of mouth, dysarthria and anarthria, dysphonia, macular degeneration, generalized anxiety disorder, depression, chronic kidney disease, stage 3, and glaucoma. According to the admission Minimum Data Set (MDS) assessment dated [DATE] R103 was cognitively intact (BIMS=15) and required limited one person assistance with activities of daily living. The MDS also documented R103 received scheduled and PRN (as needed) pain regimen and experienced pain or hurting. Review of the hospital discharge report dated 7/3/24 documented additional diagnoses that included mandible (jaw bone) pain, chronic pain due to neoplasm, cancer related pain, and post-operative pain. The discharge report also included a prescription for Oxycodone 5 mg immediate release tablet with instructions to take 1-2 tablets (5-10 mg total) by mouth every 4 hours as needed for up to 3 days, for oral cancer. R103 was administered Oxycodone 10 mg at 3:43 p.m. on 7/3/24 (prior to transfer to facility). Review of the July Medication Administration Record (MAR) documented on July 3rd, evening medications were administered except for the Oxycodone. Record review revealed the facility administered R103 pain medication on 7/4/24 at 9:30 am. R103 did not receive Oxycodone for 17 hours (last dose on 7/3/24 at 3:43 pm). Review of the physician's orders documented the following pain medication regimen to be administered: Oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl) *Controlled Drug* Give 10 mg by mouth every 4 hours for pain hold if RR <14. Start date: 7/10/24. Oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl) Give 10 mg by mouth every 4 hours as needed for as needed for pain Hold if respiratory rate less than 14. Start date: 7/4/24. Oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl) *Controlled Drug* Give 5 mg by mouth every 4 hours as needed for as needed for pain. Start date: 7/3/24. PLEASE ALL MEDICATIONS MUST BE ADMINISTERED ON TIME every 4 hours for PAIN CONTROL. Start date: 7/10/24. The following Nurse progress notes documented the following: -On 07/03/24 at 18:49 (6:49 pm) Note Text: Patient admitted from hospital at 5pm. He's being admitted due to oral cancer ( Para neo-Plastic Syndrome) . -On 07/04/2024 12:49 Note Text: Resident with C/O pain at beginning of shift. Resident medications had not been delivered pharmacy contacted once open at 9am for off (sic) to pull, C2 script was not sent to pharmacy. MD contacted and script was sent, off (sic) to pull for 5mg 1-tab Q4hrs PRN. Resident was given 1 tab at 9:30am. -On 07/09/2024 01:34 (1:34 am) Type: Behavior Note: . was waiting for a pain pill that he arrived too early for . Resident when told he had to wait 20 minutes for his pain medication, began to berate the Nurse, while threatening to report and have the Nurse fired from duty, I'll call the State on you . Nurse provided pain medication at time it was available . -On 8/11/24 00:00 (12:00 am) oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl) Give 10 mg by mouth every 4 hours for pain hold if RR <14 was on hold for behaviors. Behaviors were not documented to justify withholding pain medication. -On 08/19/2024 20:06 (8:06 pm) Note Text : Resident observed having emesis throughout the shift c/o of severe pain and cramping. Resident refused to go to radiation. Resident spoke with doctor at treatment center and stated he was having a mental break down. Dr contacted our facility to inform us of the situation. Staff nurse spoke with resident assuring him his medication will come today. Pharmacy contacted and stated medication in route. -On 8/20/2024 03:06 (3:06 am) Type: Nurses Note Text : Resident received in fair condition with current concerns of not having his scheduled Oxycodone for multiple days, resident states his mental health has been affected with the pain and overall condition related to his cancer and treatment involved . Resident states he doesn't feel well, has not slept in a few days . @ 1900 Nurse endorsed ongoing concern of missing oxycodone, script sent on previous shift, Nurse and supervisor attempted to pull medication from back up supply EXCEPT pyxis was empty - No oxycodone 5mg or 10mg was available . Resident continues to feel uneasy, afraid to go to sleep . Review of the following physician's notes documented complaints from R103 about pain: -On 8/19/2024 19:14 (7:14 pm) Physical Medicine Rehabilitation Note Text: Revision of meds. Pain is controlled most of the time. -On 8/12/2024 17:40 (5:40 pm) Physical Medicine Rehabilitation Note Text: Patient was seen today at bedside due to inability to perform ADLs Independently related to Cancer-related pain. -On 08/02/2024 11:33 (11:33 am) Physician Progress Notes Text : Medicine Progress: Previously patient had reported that his pain is well-controlled with the pain medication. However, he has been complaining of pain not being controlled to the staff (sic). - 08/01/2024 11:26 (11:26 am) Physician Progress Notes Text: Medicine Progress Note: Uncontrolled pain . Patient states pain is not well controlled. Review of the Pain care plan dated 7/5/24 documented: I have the potential for pain/discomfort r/t removal of oral cavity squamous cell carcinoma stage IV, wound to right leg. Interventions: -Administer my analgesic per orders. Give approx. 1/2 hour - 45 min before treatments or care when needed. -Anticipate my need for pain relief and respond as soon as possible to all and any complaint/signs of pain. - Attempt nonpharmacological interventions prior to giving me medication for pain. On 11/8/24 at 2:03 p.m. the Director of Nursing (DON) was interviewed regarding R103 not receiving pain medication as ordered. The DON did not recall the circumstance surrounding the resident not receiving pain medication due to behaviors. The DON said having behaviors does not justify pain medications to be withheld. Other non-pharmacological interventions could have been implemented or attempted. All medications should be administered per the physician's orders. On 11/8/24 at 3:07 LPN C was the midnight shift nurse for R103. An attempt to contact LPN C was made, however there has been no call back. On 11/8/24 at 1:01 p.m. R103 was contacted, however did not return the call until 11/13/24 at 2:24 p.m. R103 was interviewed and stated, My time at (facility) name) was horrible and I wouldn't wish what happened to me on my worst enemy. Most of my problems happened on the late shift and weekends. The one nurse (didn't remember nurse, confirmed to be LPN C) played God with my pain medications all the time. My pain medications were often not available, or the nurses just didn't want to give it to me. My pain level was always at an 8-9. I am always in constant pain, and I am trying to deal with it the best I can. It's depressing to be in pain all the time. It's more depressing when the people that are supposed to help you make you feel more helpless. Being in pain all the time will make any angry especially when denied the one thing to help make the pain better. I felt ignored when I would ask for my medication and had to wait to get it. I was forced to leave because they wouldn't help me. I had to leave for my own safety. R103 was very emotional and cried during the interview. Review of the facility's policy titled Medication Administration and General Guidelines (no date) documented the following: Medications are administered as prescribed. In accordance with State Regulations using good nursing principles and practices and only by persons legally authorized to do so . Medications are administered in accordance with written orders of the attending physician . Medications are administered within one hour of the scheduled time, unless the physician specifies a specific time then the med must be given 30 minutes prior to 30 minutes after the specified time (unless facility policy directs otherwise) . If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time . An explanatory note is entered on the reverse side of the record provided for PRN documentation. The physician must be notified when a dose of medication has not been given . Review of the facility's policy titled Pain Management (no date) documented the following: The facility will assess and identify residents experiencing pain, determine the type and severity of the pain and develop a care plan for pain management. The care plan is implemented and continually evaluated for its effectiveness. The staff monitors and documents the resident's response to pain management interventions . The pain experience is very subjective; pain is whatever the resident says it is .

This citation pertains to intake MI00135781 and MI00135936. Based on observation, interview and record review, the facility failed to implement interventions to prevent the development and worsening of a pressure ulcer for one (R707) of three residents reviewed, resulting in a facility acquired Stage 3 pressure ulcer (Full thickness tissue loss potentially extending into the subcutaneous tissue layer). Findings include: In an observation and interview on 5/24/23 at 8:57 a.m., Wound Nurse (WN) A reported R707 had a Stage 3 facility acquired pressure ulcer on the buttocks. WN A removed a heavily soiled dressing with no date from R707's buttocks. A foul smell was noted when the dressing was removed. R707 had an area the size of a grapefruit with a black center and red edges on the buttocks. WN A then provided wound care to R707's buttocks. Review of an admission record revealed, Resident #707 (R707) admitted to the facility 4/12/23 with pertinent diagnosis which included Vascular Dementia and Peripheral Vascular Disease. Review of a Minimum Data Set (MDS) assessment, with a reference date of 4/16/23 revealed R707 had no cognitive impairment with a Brief interview for Mental Status (BIMS) score of 14 out of 15 and required extensive assistance of two staff with bed mobility. R707 was at risk for pressure ulcers. Review of a Braden scale (tool used to determine pressure ulcer risk) with a date of 4/12/23 revealed R707 was at risk for pressure ulcers with a score of 15 out of 23. Review of a progress notes revealed the following: 4/12/23 at 2:00 p.m., . Resident transferred to facility for long term care. Skin warm and dry, cicatrix (scar of a healed wound) observed to B/L (bilateral) buttocks and lower extremities . 4/27/23 at 11:54 a.m., New skin issue observed by CNA (Certified Nursing Assistant), wound care notified. 5/8/23 at 4:14 p.m, Res (resident) added to wound care case load for care of sacral/bil butt stage 3 p/u (pressure ulcer) that presents with multiple pink bases with scattered yellow necrosis. there is moderate serous drainage . Review of skin assessments revealed, R707 had cicatrix (scar indicative of a healed area) to bil buttocks on 4/12/23. On 4/27/23 R707 had no skin concerns. On 5/4/23, R707 skin was clean and intact. Review of Physician orders revealed R707 had the following orders: Cleanse sacrum/bil (bilateral) butt with wound cleanser, pat dry, apply skin prep, apply santyl ointment, cover with dry dressing. every day shift for wound healing AND every 24 hours as needed for wound healing with an order date of 5/23/23. Silver Sulfadiazine Cream 1 % Apply to coccyx/bil butt topically every day shift for wound healing AND Apply to coccyx/bil butt topically every 24 hours as needed for wound healing with a start date of 4/27/23 and discontinued on 5/15/23. R707 did not have treatment orders in place between 5/15/23 and 5/23/23. Review of the Treatment Administration Record (TAR) for April and May 2023 revealed, R707 did not receive a treatment for sacrum/bilateral buttocks from 5/15-5/23. Review of weekly wound consultation progress notes revealed: On 5/8/23 R707 had a Stage 3 pressure ulcer on the sacral/bilateral buttocks which measured 6cm x 8.5cm x 0.2cm. On 5/15/23 R707 had a Stage 3 pressure ulcer on the sacral/bilateral buttocks which measured 5.8cm x 8.5cm x 0.2cm with Wound bed has a Necrotic Base granulation. Santyl daily and as needed was ordered to treat the pressure ulcer. On 5/22/23, R707 had a Stage 3 pressure ulcer on the sacral/bilateral buttocks which measured 5cm x 9cm x 0.2cm with Wound bed has a Necrotic Base granulation. Santyl daily and as needed was ordered to treat the pressure ulcer. In an interview on 5/24/23 at 2:15 p.m., WN A reported R707's wound was discovered on 4/27/23. WN A reported R707 was assessed by the Nurse Practitioner (NP) on 5/15/23 and stated, It is possible the order was discontinued and not reordered. WN A then confirmed there was no order to treat R707's pressure ulcer from 5/15/23-5/23/23. WN A reported R707's current treatment order started on 5/23/23. WN A reported R707 did not like to be repositioned because it is uncomfortable and preferred to lay on the back. In an interview on 5/24/23 at 2:39 p.m., the Director of Nursing (DON) reported the wound nurse should put in the new orders after rounding with the wound NP. The DON reported there must be an order to treat wounds and the NP recommendations should be followed for wound care. In an interview on 5/24/23 at 3:04 p.m., the DON reported she could not find a wound order for R707 during the period of 5/15-5/23/23. The DON reported there is no excuse for the treatment not to be ordered. The DON queried if the wound nurse were completing the treatment without entering the order, would she have noticed the order was missing when she documented, the DON reported she asked the same question and did not get a response. In an interview on 5/25/23 at 9:17 a.m., the DON reported skin assessments should reflect the residents skin condition, when asked why skin assessments revealed R707's skin was intact. The DON then reported R707 was not admitted with a Stage 3 pressure ulcer and was unsure of how the facility acquired pressure ulcer developed. Review of the facility policy titled Pressure Ulcer & Skin Care Management (undated) documented, A resident who enters the facility without pressure ulcers does not develop ulcers unless the resident's clinical condition demonstrates that they were unavoidable; and a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection and reduce the risk of new pressure ulcers developing . 3. The presence of any pressure ulcer, wound, or other skin conditions is documented I the designated area . 8. The nursing staff reviews the pressure ulcer prevention and treatment procedures with the resident's physician. They select the treatment procedures appropriate for the resident and type of pressure ulcer or wound. The licensed nurse implements the wound care treatment procedures in accordance with current standards of practice. 9. A licensed nurse assesses and documents that status of existing wounds weekly .