**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R14 R14's significant change Minimum Data Set (MDS) dated [DATE], indicated R14 was cognitively intact, was able to clearly communicate her needs and wishes and required extensive assistance with activities of daily living (ADL). R14's face sheet printed 1/4/24, noted diagnoses included idiopathic peripheral autonomic neuropathy (damage to the nerves that control automatic body functions), muscle weakness and hemiplegia (paralysis of one side of the body) following cerebral infarction affected left non-dominant side. R14's physician's orders printed 1/4/24, included the following orders: Oxycodone 5 mg as needed twice daily with a start date of 12/19/23; Gabapentin 300 mg twice daily with a start date of 12/14/23; Baclofen 10 mg three times daily with a start date of 12/13/23; and an order to monitor for pain every shift. During record review, records indicated R14 was previously on hospice services and was discharged from hospice on 12/6/23 due to R14 wanting to initiate therapy services. While R14 was on hospice, R14 utilized as needed morphine every four hours to help manage her pain. Upon discharge from hospice, as needed morphine was discontinued and new order was started for oxycodone as needed three times a day. On 12/19/23, oxycodone order was changed to as needed twice daily with the initiation of scheduled Gabapentin twice daily and scheduled Baclofen three times a day. R14's pain level results from 12/2023 thru 1/4/2024 indicated that R14 was having complaints of constant pain or discomfort which ranged from 6-10 out of 10 on the pain scale. During interview on 1/2/24 at 1:45 p.m., R14 stated she has pain in her left arm and down left leg that comes and goes but is pretty much constant. R14 stated her as needed pain medications were decreased from three times a day to two times a day and R14 was not happy about it as she stated she really needed them for her pain. R14 stated she was really worried about her pain when she started to do her physical therapy exercises more diligently as the pain was so horrible when doing the exercises to the point that R14 did not want to complete them. During interview on 1/4/24 at 9:51 a.m., R14's primary provider stated she did not recall being notified of the change in R14's increased pain levels anytime in December 2023 up until today 1/4/24. Provider stated she decreased R14's as needed oxycodone from three times daily to twice daily as she added scheduled gabapentin and baclofen to help manage R14's pain. Provider stated if she would have been notified of R14's increased pain levels, she would have seen R14 sooner to address pain. Provider stated she expected to be notified with any change in condition and relies on the facility staff to alert her on any changes or concerns so she could address or see the resident sooner. During interview on 1/4/24 at 11:41 a.m., director of nursing (DON) stated the nurse on the floor, who is obtaining vitals or performing assessment, notifies the provider of any changes. During interview on 1/4/24 at 1:47 p.m., physical therapist (PT) stated that R14 has pain but did try to participate in therapy as much as she could tolerate. PT stated he notified nursing of complaints of pain or discomfort. PT stated that R14's progress in therapy was slow as the increased pain or discomfort limited R14's participation. During interview on 1/4/24 at 1:50 p.m., nursing assistant (NA)-A stated R14 would call when R14 needed pain medication and NA-A would let nursing know of complaints of pain or discomfort. NA-A stated R14's pain has gotten worse and she noticed R14 had not gotten out of bed more due to her pain. During interview on 1/4/24 at 1:53 p.m., trained medication aide (TMA)-C stated when R14 was admitted to the facility she came on hospice services. TMA-C stated R14's complaints of pain have increased since discharging from hospice. TMA-C stated ice packs, repositioning or Tylenol were offered to help manage her pain and to help bridge the gap from the oxycodone coverage. TMA-C stated he would let the nurse or DON know of complaints of increased pain so that they could notify the provider. During interview on 1/4/24 at 4:32 p.m., DON stated he expected the provider should be notified with change in condition or anything out of the ordinary. DON stated he expected R14's increased complaints of pain or discomfort, should have been reported to the provider as it could potentially cause great harm. A facility Pain management policy was requested and was not received. Based on interview and document review, the facility failed to ensure pain management was provided consistent with professional standards of practice and the residents' goals and preferences for 2 of 2 residents (R131 and R14) reviewed for pain managment. This deficient practice caused actual harm for R131, who experienced unmanaged pain, disturbed sleep patterns and who had reports of pain. Findings include: R131's discharge Minimum Data Set (MDS) dated , 9/23/23, identified resident admitted to the facility 9/22/23 from an acute care hospital for aftercare following surgery on the nervous system and diagnoses of spondylolisthesis lumbar region (a spinal disorder in which a vertebra slips forward onto the bone below it), radiculopathy lumbar region (a pinched nerve), spinal stenosis (a narrowing of the spinal canal that can put pressure on the spinal cord and nerves within the spine), chronic pain and muscle weakness. R131 had clear speech, the ability to make herself understood and had clear comprehension. R131's hospital Discharge summary dated [DATE], identified R131 admitted [DATE] and underwent surgical procedures including lumbar hemllaminectomy with [NAME] repair (a spine surgery that involves removing one of the two laiminae on a vertebra to relieve excess pressure on the spinal nerves) and was discharging to the facility on 9/22/23 for surgical aftercare for low back pain, skilled nursing services and therapy. The same discharge summary included a pain assessment dated [DATE], indicating resident was having aching, constant pain in the right buttocks and down the right leg. The same discharge summary included orders for ibuprofen (a pain medication) 800 milligrams (mg) every eight hours as needed (prn), oxycodone-acetaminophen (a pain medication) 5-325 mg every four hours prn, last received on 9/22/23 at 8:51 a.m., and diazepam (a medication for muscle spasms) 5 mg every six hours prn last received on 9/21/23 at 2:06 a.m. The hospital discharge summary identified these orders were sent to the facility contracted pharmacy. The same discharge summary was faxed to the facility 9/22/23 at 11:59:14 a.m., as identified on the fax cover sheet. The facility admissions notification form identified R131 as a confirmed admission 9/22/23 at 12:00 p.m. R131's 48-hour care plan dated 9/22/23 at 2:52 p.m., identified a section available for pain and comfort but lacked identification of focus, goal, and interventions. When interviewed on 1/3/24 at 9:48 a.m., R131's spouse stated resident was in the hospital for three days following a back surgery in which the dura (membrane that encases the spinal cord) had been cut by accident resulting in the need for skilled nursing care and therapy. R131's spouse stated resident admitted to the facility on [DATE] at approximately 1:30 p.m. and was told resident's medications had not been delivered yet. R131's spouse stated he left the facility then returned at approximately 5:00 p.m. and was told resident's medications were still unavailable. R131's spouse went home and returned at approximately 9:30 p.m. He stated he was again told resident's medications had not been delivered. R131's spouse stated he left resident with his cell phone and returned home. He received a call from R131 at approximately 10:30 p.m. because resident had used the call light to request help from staff to close the room blinds for privacy and no staff had come. R131's spouse stated he called the facility two times and no staff answered so he returned to the facility to close the blinds, spoke with staff regarding the lack of pain medication and told them he would be taking resident home in the morning. R131's spouse stated resident had asked for her ordered oxycodone-acetaminophen pain medication twice at approximately 3:30 p.m. and again at approximately 10:00 p.m. for pain she was rating at eight to nine out of 10. R131 was told the medication was unavailable because they were not delivered from pharmacy yet. R131's spouse stated he returned to the facility the next morning on 9/23/23 at approximately 7:30 a.m. and told staff he was checking her out because she wasn't getting adequate pain control. R131's spouse stated staff brought her breakfast and oxycodone-acetaminophen pain medication at approximately 8:15 a.m. before leaving. R131's progress note dated 9/22/23 at 10:30 p.m., indicated R131 had been turning on call light multiple times throughout shift for prn pain medications. Staff informed resident multiple times her medications had not yet arrived from pharmacy. Resident's husband came up to the nurse's desk and became upset with the nurse on shift because resident does not have any medication and staff did not know the exact time the medications would be delivered. The same progress notes also indicated a call was made to the pharmacy to determine when her medications would be delivered and the hospital discharge orders were again faxed, however lacked documentation of attempts to obtain a code to access medications from the facility cubex (emergency medication machine the facility had in place for ordered medications not yet delivered). R131's progress note dated 9/23/23 at 8:47 a.m., identified the resident's husband was upset with staff when staff came in because still had not yet received any prn pain medication all night from staff. The progress note also indicated R131 and her spouse communicated no one went in to check on her and resident stated she requested hot and cold packs and no one would take them in. Resident asked for an ice pack this morning and staff took it in right away. When nurse pulled meds from the cubex and took them into R131's room, her spouse stated they were leaving and wanted to discharge. R131's medical record indicated staff had documented her pain rating at 5 at on 9/23/23 at 4:38 a.m. and 8:27 a.m. R131's facility medication administration record (MAR) dated 9/1/23-9/30/23, identified orders for diazepam 5 mg every six hours as needed for pain with a start date and time of 9/22/23 at 2:00 p.m., but lacked evidence of the medication being administered. The same MAR identified an order for oxycodone-acetaminophen 5-325 mg every four hours as needed for pain, take one tablet for pain zero to five and two tabs for pain six to ten and was documented as being given one time on 9/23/23 at 8:27 a.m. R131's order for ibuprofen was not on the MAR indicating the order was not entered. When interviewed on 1/3/24 at 10:30 a.m., the facility pharmacy consultant (Pharm D)-A stated the facility has normal scheduled medication deliveries. The facility also has an emergency supply of medications in a dispensing machine referred to as a cubex or medbank. The Pham-D-A stated in the cubex are over 200 available medications that could be utilized per order prior to normal scheduled deliveries including pain medication such as oxycodone-acetaminophen. As long as the pharmacy had the prescription for R131's oxycodone-acetaminophen, staff could call the pharmacy to request a code to access the medication from the cubex onsite per facility protocol. Pharm-D -A stated the list of available medications in the cubex was usually posted right next to the machine. The facility staff were trained on the use of the machine when they were installed. The pharmacy Cubex medication inventory list dated 1/2021, indicated several available analgesics (pain medication) including oxycodone-acetaminophen 5-325 mg. When interviewed on 1/3/24 at 12:13 p.m., The Pharm-D-B stated R131's oxycodone-acetaminophen prescription order was received at the pharmacy from the hospital on 9/22/23 at 9:22 a.m The Pharm-D-B stated facility staff could have called to get a code to access the medication whenever R131 needed it. The Pharm-D-B verified no such request had been made. The Pharm-D-B confirmed the resident's demographic information had been entered into their system on 9/22/23 at 3:00 p.m., but the faxed hospital discharge orders from the facility were not received until 8:40 p.m. which would be the reason her medications were not delivered earlier. Despite this, staff could still access medications from the cubex unit if the facility had orders. The Pharm-D-B stated the reason facilitiy had the cubex in place was so medications could be provided between regular medication deliveries. The Pharm-D-B stated because R131 was rating her pain at eight to nine out of 10, he would consider the lack of provision of her ordered and available pain medication to be a significant error by the facility. When interviewed on 1/3/24 at 4:20 p.m., registered nurse (RN)-B confirmed he had worked at the facility approximately three years and was working the overnight shift on 9/22/23 to 9/23/23. RN-B stated if a resident was in pain, he would administer pain medication if ordered. RN-B stated if the medications had not come from the pharmacy, staff had the ability to pull medication from the cubex. RN-B stated if the medication was a narcotic or controlled substance like oxycodone-acetaminophen staff could call the pharmacy and get a code to pull it from the cubex. When asked if he had received a request from R131 for pain medication or ice packs, RN-B stated he did not remember. When interviewed on 1/4/24 at 11:45 a.m., R131 stated she last received her oxycodone-acetaminophen pain medication approximately 9:00 a.m. in the hospital before admitting to the facility and did not receive another dose from the facility until the morning of 9/23/23 at approximately 8:30 a.m. She started experiencing pain in her right buttocks and right leg approximately 3:00 p.m. after admitting to the facility and described it as severe, stabbing, aching in the nerve and rated it eight to nine out of ten. Her pain made it difficult to walk, sit on the toilet, get comfortable and sleep throughout her stay. R131 stated she asked facility staff for the pain medication prescribed for her in the hospital at least two to three times and was told it was unavailable. She asked staff for ice packs, but none were provided. When she left the facility the morning of 9/23/23, her son-in-law and husband had to carry her into their home because she was in too much pain to walk. Her husband got her ordered medications through their local pharmacy approximately 12:00 p.m. after returning home. R131 stated because she went nearly 24 hours without pain medication it took two days to feel any pain relief after resuming use of her ordered oxycodone-acetaminophen. R131 stated after approximately 12 days her pain began to diminish and she was able to gradually resume walking and regular activity. She believed, had she received the requested doses of her pain medication in the facility when she had asked, it would not have taken so long to get relief and recover normal function. When interviewed on 1/4/24 at 1:17 p.m., RN-A stated she worked for the facility approximately one year and four months. RN-A stated she was the nurse on duty 9/22/23 on the facility p.m. shift the day R131 arrived. She remembered the resident being very upset about her pain, asking for pain medications, and made racist comments about staff. R131's husband was upset because her medications had not been delivered. RN-A stated normally the facility pharmacy made medication deliveries around 5:30 p.m. and then again at 10:30 p.m. RN-A stated the facility has a cubex that staff could call the pharmacy to obtain a code to retrieve narcotics out of if needed but at that time she didn't think she could do that because when she called the pharmacy regarding the time of the next delivery they requested for the hospital discharge orders to be faxed again. She did not ask for a code for the cubex to obtain R131's hydrocodone-acetaminophen because she thought she had to wait for the pharmacy to deliver R131's medications. RN-A stated she communicated this information before leaving her p.m. shift to RN-B when he arrived for the night shift. RN-A stated this was the first time admitting a new resident and learned she could have called for a code and administered the medication because the facility already had the orders, and the pharmacy had the prescription. RN-A stated she returned the next morning for a day shift and by that time the resident's medications had been delivered so she administered her oxycodone-acetaminophen at that time. When interviewed on 1/4/24 at 2:58 p.m., the director of nursing (DON) stated through the facility referral process it had been determined the facility could admit and care for R131. The DON stated the facility received R131's orders approximately 12:30 p.m. and entered them approximately 2:00 p.m. into her EMR (electronic medical record) Normally the facility process for admissions is to receive the orders and send them to the pharmacy. If the orders were sent to the pharmacy before 3:00 p.m., then medications would be delivered approximately 5:00 p.m. and if the orders were sent to the pharmacy after that, the next delivery was approximately 10:00 p.m. Even if R131's medications had not been delivered the facility staff had the ability to pull medications from the cubex by calling the pharmacy and ensuring they had the prescription. The DON stated some of the staff trained on the use of the cubex machine in May of 2023. Any staff who missed that training were individually trained by himself. The DON stated he was made aware of R131 wanting to discharge when RN-A called him on the morning of 9/23/23. RN-A informed him of R131's racist comments and assumed this was the reason she wanted to leave as the facility employs African American staff. The DON stated he had not investigated R131's concerns regarding not receiving pain medication and did not know why RN-A and RN-B did not call the pharmacy to obtain an authorization code to administer it from the cubex. The DON stated it was important to ensure R131 received pain medications related to her diagnoses, recent surgery and reported pain because the facility agreed to provide her services including pain control and she didn't get that. The facility MedBank Training staff signature form dated 5/2/23 indicating training on use of the cubex was not signed by RN-A or RN-B and the DON did not provide other documentation the training had been provided to them. The facility policy and procedure Medication Ordering and Receiving from Pharmacy dated May 2022, identified Emergency pharmacy service is available on a 24-hour basis. Emergency needs for medication are met by using the facility's approved emergency medication supply or by special order from the provider pharmacy. The provider pharmacy supplies emergency medications including emergency drugs, antibiotics, controlled substances, products for infusion in limited quantities in portable containers, automatic dispensing systems incompliance with applicable state regulations. The Facilty Assessment Tool dated 2/28/23, identified pain management including assessment of pain, pharmocologic and nonpharmocological pain management as a service provided based on resident need.