**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, review of facility policy, review of hospital records, review of facility investigation, review of employee personnel files and staff and resident interview, the facility failed to ensure Resident #29 was provided adequate assistance and the use of required footrests during transport to prevent an avoidable injury. This resulted in Actual harm on 06/27/23 when Occupational Therapist (OT) #700 was transporting the resident in a wheelchair without proper footrests being in place. During the transport, the resident's right leg fell to the ground and went under the wheelchair. The resident complained of pain and was noted to have swelling to the area. An x-ray, obtained on 06/28/23 (a day after the incident) revealed the resident had a closed displaced fracture of the medial malleolus of the right tibia. This affected one resident (#29) of three residents reviewed for accidents. The facility census was 63. Findings include: Review of the medical record for Resident #29's revealed an admission date of 09/30/22. Resident #29 had diagnoses including multiple sclerosis (MS), morbid obesity due to excess calories, difficulty in walking, muscle weakness, and other symbolic dysfunctions. Review of the care plan for Resident #29 dated 10/02/22, revealed the resident had limited physical mobility related to MS and muscle weakness. Interventions included the resident used a wheelchair and was totally dependent on staff for locomotion. Review of a facility document titled Certificate of Medical Necessity dated 10/31/22 for Resident #29, revealed the resident had history of MS, impaired coordination, inability to complete mobility and contracture to right knee with impaired ability to self-propel. The document revealed the resident required a customized wheelchair. Resident #29 required elevated leg rests due to increased edema in the bilateral lower extremity, and she was unable to bend her right knee past 10 degrees due to knee contracture. Therefore, the document indicated the resident must keep her right leg straight at all times and in order to get right leg off the ground, the facility must use an elevated leg rest. The resident's leg had to be off the ground in order for her to be able to self-propel. The resident was ordered an Access Tilt in Space wheelchair through Sunrise medical. The customized wheelchair was equipped with reclining back, elevated leg rests due to resident's 10-degree right knee flexion and a larger back gap. The document was signed by Physician #901. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #29 revealed the resident was cognitively intact. The assessment revealed Resident #29 required total dependence of two (staff) for transfers and extensive assistance of one (staff) for locomotion. Review of the occupational therapy evaluation dated 06/26/23 for Resident #29, revealed the resident was being seen with goals to increase activity tolerance for functional activities of choice, improve ability to wheel at least 50 feet, make two turns once seated in the wheelchair, safely self-propel her wheelchair in her room and to safely negotiate obstacles while self-propelling her wheelchair. Resident #29 was dependent for safely wheeling at least 50 feet and making two turns, required substantial or maximum assistance for self-propelling her wheelchair in her room and negotiating obstacles while self-propelling her wheelchair. Review of the controlled drug record dated 06/27/23 for Resident #29, revealed the resident was given Tramadol 50 milligrams (mg) one tablet by mouth for pain on 06/27/23 at 6:00 P.M. Review of a progress note dated 06/27/23 at 6:40 P.M. for Resident #29, revealed the resident was being transferred in her wheelchair by the therapist when the resident's right foot got caught under the wheelchair. Resident #29 complained of pain being a five out of ten (zero was no pain and 10 was severe pain) and pain medication (over the counter Tylenol) was administered. The note revealed Resident #29's range of motion was at baseline. Review of an undated Occupational Therapist (OT) #700's witness statement revealed on 06/27/23, OT #700 was pushing Resident #29 down the hall in her wheelchair and Resident #29 was holding her legs up because her legs have trouble bending enough to use the leg rests. While moving down the hallway, Resident #29 dropped her legs without warning and her right leg twisted under the chair. OT #700 immediately backed the chair up and brought her leg in front of her. OT #700 got her footrests and elevated both legs as best she could and returned Resident #29 to her room. OT #700 was delayed in speaking to the nurse immediately about the incident but spoke with her within approximately a half an hour. Review of a progress note dated 06/28/23 at 9:24 A.M. for Resident #29, revealed the facility notified the nurse practitioner (NP) of Resident #29's right foot being swollen and painful post a wheelchair incident on 06/27/23. A new order was obtained for an x-ray. Review of an imaging report dated 06/28/23 for Resident #29, revealed the resident had an acute appearing medial malleoli fracture with soft tissue swelling. Review of a progress note dated 06/29/23 at 8:39 A.M. for Resident #29, revealed the facility notified the NP of the right foot x-ray results and obtained orders for Resident #29 to be treated. Resident #29 was transferred to the hospital for further evaluation and treatment of her right ankle per Resident #29 and her family's request. The NP, Resident #29 and the resident's family were made aware of the new orders, and all were in agreement with plan of care. Review of a progress note dated 06/29/23 at 12:55 P.M. for Resident #29, revealed the wheelchair company was to come in to assess the wheelchair. Review of a progress note dated 06/29/23 at 7:17 P.M. for Resident #29, revealed the resident returned to the facility by stretcher and a fracture was noted to Resident #29's right foot. Oxycodone 5/325 (narcotic /pain) milligrams (mgs) one to two tablets by mouth every six hours as need for five days was ordered and a follow up appointment with the orthopedic surgeon was ordered as soon as possible. Review of a progress note dated 06/29/23 at 12:43 P.M. for Resident #29, revealed the interdisciplinary team (IDT) met regarding the incident. Upon investigation, the IDT found that Resident #29 was being wheeled in a wheelchair by therapist (identified as Occupational Therapist #700) to the therapy room. During wheelchair transportation, Resident #29 said to the therapist that her foot was caught under wheelchair. Resident #29 stated the therapist did not hear her and was still pushing her when resident yelled out that her foot hurt. The therapist then stopped pushing resident. Resident #29's foot was adjusted. The nurse assessed the resident, range of motion was initiated, and a pain assessment performed with a score of a four to five out of ten. Pain medication was given, and ice was offered but Resident #29 declined as she stated she was always cold and cold hurts. Resident #29 was put to bed and the foot of bed was elevated. Staff education was provided an x-ray was obtained. Review of the hospital records dated 06/29/23 for Resident #29, revealed the resident presented to the emergency room for evaluation of right leg, ankle, and foot pain. Resident #29 stated that she was wheelchair bound with a history of MS. Resident #29 was doing physical therapy and her foot got caught in the wheelchair and she heard a pop and had pain. Resident #29 had an x-ray of her ankle done on 06/28/23 and it showed a fracture. Resident #29 stated she was having some significant pain. An x-ray was taken and showed a non-displaced or minimally displaced fracture of the medial malleolus of the right ankle. Resident #29 was diagnosed with a closed displaced fracture of the medial malleolus of right tibia. Resident #29 was placed in an ace wrap and an air cast, was given a prescription for Oxycodone for pain control and ordered to schedule an appointment with orthopedic as soon as possible. Review of RN #902's disciplinary notice dated 06/29/23, revealed the nurse failed to follow proper procedures by not notifying the physician of an acute physical change or incident involving a resident and the family was not notified. Review of Registered Nurse (RN) #902's witness statement dated 06/29/23, revealed while RN #902 was doing rounds on 06/27/23, Resident #29 called her into her room and asked her if the therapist told her what happened. RN #902 stated no and Resident #29 proceeded to tell her that while she was being wheeled to therapy in her wheelchair by the therapist, her right foot got caught under the wheelchair and the therapist did not know and kept wheeling. The resident then yelled for the therapist to stop, and the therapist then rolled her back to her room. RN #902 told Resident #29 she did not hear anything from the therapist and that she would reach out. The resident was still sitting in her chair. She raised her foot up and down and flexed back and forth and it was not red or swollen but was tender. RN #902 administered as needed pain medication and Resident #29 refused ice because of her arthritis. RN #902 asked the resident if she felt like she needed an x-ray and the resident stated no. RN #902 told Resident #29 she would get an x-ray if it was still bothersome when she came back to work on 06/28/23. As she went back to the nursing station, she saw the therapist in the hallway asked if she had something to say to her because Resident #29 told her what happened. The therapist stated I'm sorry, I forgot to tell you her foot was caught in her wheel underneath it. I meant to tell you. RN #902 proceeded to chart the situation and she was due back the next day. RN #902 gave report to the night shift nurse and the next morning the unit manager ordered the x-ray. Review of a physician order dated 06/30/23 for Resident #29, revealed the resident had an order to follow up with orthopedics on 07/24/23 at 8:30 A.M. Review of OT #700's verbal warning disciplinary action form dated 06/30/23 revealed OT #700 failed to report the incident with Resident #29 immediately to nursing staff and OT #700 failed to use foot pedals when transporting residents at all times. Interview on 07/03/23 at 10:56 A.M. with OT #700, revealed she was wheeling Resident #29 down the hallway and Resident #29 was holding both of her legs up in the air. OT #700 stated the leg and footrests were not on the wheelchair due to Resident #29's legs not fitting properly on her current leg and footrests. OT #700 stated Resident #29 dropped her legs unexpectedly while she was pushing her down the hall and Resident #29's right leg and foot got caught and twisted in the wheelchair. Interview on 07/03/23 at 11:00 A.M with Therapy Manager #900, revealed Resident #29 had a specialized wheelchair, and she was aware that her legs did not fit on the wheelchair leg and footrests appropriately prior the incident due to her knee not bending. Therapy Manager #900 stated the wheelchair company was scheduled to come and look at the wheelchair since the incident occurred. Interview on 07/03/23 at 11:29 A.M. with Resident #29, revealed the resident broke her right ankle and stated the therapist was pushing her wheelchair on the way to therapy. Resident #29 reported she had her right leg up on her left leg because the right leg did not work well, and the right leg fell off the left leg and went under the wheelchair. Resident #29 stated she did not have leg and footrests on her wheelchair at the time of the incident because her legs did not stay on them correctly. Resident #29 reported she wanted to use the leg and footrests on her wheelchair. Observation at the same time, revealed Resident #29's customized wheelchair being stored in her room with two leg rests sitting on the wheelchair. Interview on 07/03/23 at 3:48 P.M. with the Director of Nursing (DON), revealed OT #700 was pushing Resident #29 down the hallway on 06/27/23 at an unknown time when the resident stated ouch. The DON reported OT #700 did not hear the resident and Resident #29 yelled out again and OT #700 stopped. The DON stated Resident #29's foot was twisted under the wheelchair. The DON reported OT #700 returned Resident #29 to her room and did not notify the nurse. Resident #29 was talking about the incident to another resident and RN #902 overheard them talking about the incident. The nurse assessed the resident for pain on 06/27/23 and Resident #29 had no initial signs of swelling and was given as needed pain medication. The DON stated RN #902 told Resident #29 that she would contact the doctor the next day if her foot hurt. The DON reported RN #902 did not contact the doctor, family, or management on 06/27/23 regarding the incident which was against the facility's policy. The DON stated management found that RN #902 charted about the 06/27/23 incident on 06/28/23 and the family and physician were contacted based upon that progress note. The DON reported Resident #29 was ordered an x-ray on 06/28/23 and the results came back on 06/29/23 and found Resident #29 had an ankle fracture. Resident #29's family and physician were notified on 06/29/23 and Resident #29 was sent to the hospital for evaluation. The DON stated RN #902 was terminated for failing to notify the physician or family of the incident on 06/27/23 involving Resident #29 and OT #700 was written up for failing to notify the nurse and pushing Resident #29 in a wheelchair without the leg and footrests. The DON reported the facility educated therapy staff on change in condition, but the facility did not educate any other staff on the use of leg and footrests. The DON also stated the facility did not evaluate all resident wheelchairs for leg and footrests or proper functioning. Telephone interview on 07/05/23 at 12:07 P.M. with RN #902, revealed she was doing her rounds on 06/27/23 at around 5:30 P.M. or 6:00 P.M. when Resident #29 told her about the injury. Resident #29 told RN #902 that she was being pushed in a wheelchair by the therapist when her foot went underneath it because she did not have foot or leg rests on her wheelchair and the therapist was not aware until she told her to stop. RN #902 stated the therapist never reported the incident to her. RN #902 reported she assessed Resident #29's foot and found that it was not red or swollen but Resident #29 stated it was slightly painful. RN #902 reported that she provided Resident #29 an as needed Tramadol (narcotic/pain) and informed the night shift nurse of the incident. RN #902 stated she did not notify the family or doctor. RN #902 reported she found the therapist about 10 minutes after she spoke with Resident #29 and the therapist stated that Resident #29's foot got tangled in the wheelchair when she was taking her to therapy in her wheelchair. Telephone interview on 07/05/23 at 12:21 P.M. with OT #700, revealed the incident occurred between 12:30 P.M. and 1:00 P.M. on 06/27/23 and she did not observe Resident #29's leg or foot tangled under her wheelchair because she backed the wheelchair up after she felt resistance and the resident yelled out. OT #700 stated she notified the nurse approximately 30 minutes after the incident and she returned Resident #29 to her room instead of doing therapy with her. OT #700 reported she got Resident #29's leg and footrests from her room to transport Resident #29 back to her room, but Resident #29's right leg did not fit on the foot plate properly due to her knee not bending so she propped it up on the foot plate. Review of OT #700's personnel file revealed OT #700 was hired by the therapy company at the facility on 11/08/21 and was educated on accident prevention on 09/20/22. Review of the facilities in service on reporting acute physical and mental changes of incidents dated 06/29/23 revealed therapy staff including OT# 700 were educated on reporting changes. Review of the facility's change in condition policy dated February 2021, revealed the facility will notify the resident, his or her attending physician and the resident representative of changes in the resident's medical condition. This deficiency represents non-compliance investigated under Complaint Number OH00143879.

Based on record review, observation, staff interviews, review of facility policy, and review of guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to ensure physician-ordered and/or care planned interventions were implemented for the treatment of pressure ulcers, failed to thoroughly assess a resident's skin and failed to identify a resident's pressure ulcers until they had already reached an advanced stage. This resulted in Actual Harm to Resident #34 who was admitted to the facility without pressure ulcers and developed two avoidable unstageable pressure ulcers to the left foot. This affected one (#34) of three residents reviewed for pressure ulcers. The facility census was 68. Findings include: Review of the medical record for Resident #34 revealed an admission date of 09/25/17 with a diagnoses including cerebral infarction, dementia, and diabetes mellitus (DM). Review of the Minimum Data Set (MDS) for Resident #34 dated 10/27/22 revealed the resident was cognitively impaired and required extensive assistance of one to two staff with activities of daily living (ADL's). Review of the pressure ulcer risk assessment for Resident #34 dated 04/12/22 revealed the resident was at moderate risk for the development of pressure ulcers. Review of the care plan for Resident #34 updated 11/25/22 revealed the resident was at risk for pressure related ulcers due to insulin-controlled diabetes, hemiparesis, limited mobility, dependence on staff for repositioning and turning, and urinary incontinence. Resident #34 had a diagnosis of expressive aphasia and was not able to indicate her need for repositioning. Resident #34 developed a deep tissue injury (DTI) to the underside of her left first metatarsal and the underside of her left great toe which was first identified on 11/15/22. Interventions included the following: soft preventative boots on as tolerated by resident (added 11/25/222), treat areas as ordered by wound nurse practitioner (NP), encourage/assist to shift weight in wheelchair frequently, turn and reposition often and as needed, administer medications as ordered, monitor/document for side effects and effectiveness, administer treatments as ordered and monitor for effectiveness, apply lotion to dry skin areas after bathing, do not massage over bony prominence's and use mild cleansers for peri-care/washing, treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort, pressure relieving mattress. Review of the weekly skin observation tool for Resident #34 dated 10/25/22 revealed the resident had no new areas of skin impairment. Review of the medical record for Resident #34 revealed there were no weekly skin observations conducted between 10/25/22 and 11/15/22. Review of the wound NP note for Resident #34 dated 11/15/22 revealed on 11/01/22 the facility reported no new open areas for resident. Resident #34 had an unstageable pressure ulcer to her left great toe which measured 2.5 centimeters (cm) in length by 1.5 cm in width by 0.1 cm in depth and an unstageable pressure ulcer to her left foot which measured 2.0 cm in 1.5 width by 0.1 cm in depth. Offloading boots were recommended to promote healing. Review of the facility pressure ulcer assessment for Resident #34 dated 11/16/22 revealed the resident developed a pressure ulcer to her left toe which was classified as a suspected deep tissue injury (DTI) and measured 2.5 centimeters (cm) in length by 1.5 cm in width by 0.1 cm in depth and a pressure ulcer to her left foot which was also classified as a suspected DTI which measured 2.0 cm in 1.5 width by 0.1 cm in depth. Treatment plan included skin prep as ordered to the areas and to offload resident's heels. Review of the November 2022 monthly physician orders for Resident #34 revealed orders dated 11/25/22 for staff to apply skin prep to areas to left foot once per shift and an order for resident to have pressure preventative boots on her feet at all times. Review of the November 2022 Treatment Administration Record (TAR) for Resident #34 revealed the skin prep treatments to resident's left foot were not documented as administered until 11/25/22. The heel boots were not documented as applied until 11/25/22. Observation on 11/28/22 at 10:47 A.M. of Resident #34 revealed the resident was in bed and her heel boots were sitting on the dresser and were not on resident's feet. Interview on 11/28/22 at 10:53 A.M. with State Tested Nursing Assistant (STNA) #480 confirmed Resident #34 did not have heel boots on her feet. STNA #480 confirmed she was not Resident #34's aide. Interview on 11/28/22 at 10:54 A.M. of Licensed Practical Nurse (LPN) #180 confirmed Resident #34 did not have heel boots on her feet and she was supposed to have them on at all times. LPN #180 confirmed she thought STNA #490 was the aide for Resident #34 and suggested surveyor interview STNA #490 regarding resident's heel boots. Interview on 11/28/22 at 11:01 A.M. with STNA #490 confirmed she was not the aide for Resident #34 and had not provided any care for her on 11/28/22 and had not been in her room. Interview on 11/28/22 at 11:02 A.M. with LPN #180 and STNA #480 confirmed there was a misunderstanding regarding the schedule, and STNA #480 was the assigned aide for Resident #34. STNA #480 confirmed she had been working since 7:00 A.M. on 11/28/22. STNA #480 stated she provided incontinence care to Resident #34 at approximately 7:15 A.M. and delivered her breakfast tray but she had not applied resident's heel protectors because she was not the resident's assigned aide. Interview on 11/28/22 11:42 A.M. with Registered Nurse (RN) #540 confirmed Resident #34 had pressure ulcers to her left foot and left great toe which were first identified on 11/15/22. RN #540 confirmed resident had a physician's order to wear the heel boots at all times as tolerated. RN #540 confirmed resident was unable to don and doff the boots per self. Observation on 11/29/22 at 8:34 A.M. of Resident #34 revealed the resident was in bed and her heel boots were sitting on the dresser and were not on resident's feet. Interview on 11/29/22 at 8:34 A.M. of STNA #500 confirmed Resident #34 was in bed and her heel boots were sitting on the dresser and were not on the resident's feet. STNA #500 confirmed she was her aide for the day and had started work at approximately 7:00 A.M. and she had not attempted to don the boots to resident's feet. Interview on 11/29/22 2:38 P.M. with wound NP #811 confirmed Resident #34 had developed two unstageable pressure ulcers to her left foot approximately two weeks prior. NP #811 confirmed Resident #34 dug her heels into her mattress due to contracture's to the lower extremities. NP #811 confirmed Resident #34 should have heel boots on at all times. Observation of wound care on 11/29/22 at 4:08 P.M. for Resident #34 per RN #540 and LPN #814 revealed the resident was resting in bed with her heel boots in place. Observation revealed RN #540 measured a wound to the underside of Resident #34's left great toe which measured 2.0 cm in lengthy by 1.0 cm in width. RN #540 then measured a wound to the underside of Resident #34's left metatarsal which measured 1.5 cm in length by 1.5 in width. There was no depth to the wounds and both wound beds were reddish-brown in color. RN #540 applied skin prep to Resident #34's wounds. Interview on 12/01/22 at 7:59 A.M. with RN #540 confirmed the facility nurses should conduct a weekly skin assessment and document the results in the residents' electronic medical record. RN #540 confirmed the facility had not conducted Resident #34's weekly skin assessments from 10/25/22 until 11/16/22. RN #540 confirmed the skin assessment on 10/25/22 revealed Resident #34 had no new open areas, and the next subsequent skin assessment was not conducted until 11/16/22 and the resident was found to have developed two pressure ulcers to her left foot. RN #540 confirmed the treatment order for skin prep and the order for heel boots were not initiated until 11/25/22. Review of the facility policy titled Wound, and Skin Prevention Program dated January 2018 revealed a weekly skin assessment should be done by the charge nurse and any skin issues identified should be assessed and a treatment plan should be initiated. Further review of the policy revealed recognizing the need for wound and skin preventative care was everyone's responsibility including STNA's. Review of the NPUAP guidelines dated 2014 pages 70-71 at https://npiap.com/general/custom.asp?page=2014Guidelines revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, edema, and induration. Further review of the guidelines revealed ongoing assessment of the skin was necessary in order to detect early signs of pressure damage. Visual assessment for erythema (redness of the skin) was the first component of every skin inspection. Skin redness and tissue edema resulting from capillary occlusion was a response to pressure, especially over bony prominence's. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominence's including the sacrum, ischial tuberosities, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment. Review of the NPUAP guidelines dated 2014 page 115 revealed ideally, heels should be free of all pressure, a state sometimes called floating heels. Pressure can be relieved by elevating the lower leg and calf from the mattress by placing a pillow under the lower legs, or by using a heel suspension device that floats the heel. Consequently, the pressure will instead spread to the lower legs, and the heels will no longer be subjected to pressure.

Based on record review, observations, staff interview, review of facility policy, review of guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), and review of an online resources regarding pain in dementia residents, the facility failed to provide pain management interventions in accordance with the resident's care plan. This resulted in Actual Harm to Resident #34 who had acute fractures to her right distal tibia/fibula and two unstageable pressure ulcers to her left foot and the resident was not medicated for pain prior to wound care which resulted in the resident exhibiting signs of severe pain. This affected one (#34) of one residents reviewed for pain management. The facility census was 68. Findings include: Review of the medical record for Resident #34 revealed an admission date of 09/25/17 with a diagnoses including cerebral infarction, dementia, and diabetes mellitus (DM.) Review of the Minimum Data Set (MDS) for Resident #34 dated 10/27/22 revealed resident was cognitively impaired and required extensive assistance of one to two staff with activities of daily living (ADL's). Review of the care plan for Resident #34 dated 12/27/21 revealed the resident was on pain medication therapy related to chronic pain and contracture's. Interventions included the following: administer analgesic medications as ordered by physician, monitor/document side effects and effectiveness every shift, review for pain medication efficacy, assess whether pain intensity is acceptable to resident or if change in regimen is required, report/consult physician as needed to obtain desired outcome. Review of the care plan for Resident #34 updated 11/25/22 revealed the resident was at risk for pressure related ulcers due to insulin-controlled diabetes, hemiparesis, limited mobility, dependence on staff for repositioning and turning, and urinary incontinence. Resident #34 had a diagnosis of expressive aphasia and was not able to indicate her need for repositioning. Resident #34 developed a deep tissue injury (DTI) to the underside of her left first metatarsal and the underside of her left great toe which was first identified on 11/15/22. Interventions included the following: administer medications as ordered, monitor/document for side effects and effectiveness, administer treatments as ordered and monitor for effectiveness, treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort. Review of nurse progress note for Resident #34 dated 11/15/22 revealed the aide notified the nurse the resident had a bruise to the right inner foot. Nurse assessed Resident #34 and noted the resident's right ankle and foot were swollen. The attending physician was notified and gave an order for an x-ray to the right foot. Review of nurse progress note for Resident #34 dated 11/15/22 revealed the x-ray to the right foot indicated acute distal tibia/fibula fractures were noted. Review of x-ray report for Resident #34 dated 11/15/22 revealed there were distal tibia/fibula fractures to the right ankle with slight malalignment, soft tissue swelling, and joint space narrowing. Review of the November 2022 monthly physician orders for Resident #34 revealed orders dated 11/08/22 for resident to receive MS Contin tablets twice daily routinely for pain and morphine sulfate (liquid concentrate) every four hours as needed for pain. Review of the November 2022 Medication Administration Record (MAR) for Resident #34 revealed the resident was offered routine MS Contin on 11/29/22 at 8:00 A.M. but refused the medication. Further review of the MAR revealed Resident #34 did not receive any as needed doses of morphine sulfate liquid on 11/29/22 prior to wound care. Reviewed of the controlled substance sheets for Resident #34 for MS Contin tablets and morphine sulfate liquid revealed the resident did not receive these medications on 11/29/22 prior to wound care. Observation of wound care on 11/29/22 at 4:08 P.M. for Resident #34 per Registered Nurse (RN) #540 and Licensed Practical Nurse (LPN) #814 revealed the resident cried out in pain when nurses repositioned the resident in the bed prior to wound care to her left foot. RN #540 and LPN #814 did not conduct an assessment of Resident #34's pain and assured the resident they would perform treatment as quickly as possible. Resident #34 cried and moaned continuously as staff removed heel protectors, measured wounds to left foot, applied wound treatment, and reapplied heel protectors. Tears were noted running down Resident #34's face during care. Interview on 12/01/22 at 4:20 P.M. with RN #540 confirmed Resident #34 was not able to rate her pain using a numerical scale but the facility rated her pain based on an observation of her objective symptoms including breathing, negative vocalization, facial expression, body language, and consolability consistent with the Pain Assessment in Advanced Dementia (PAINAD) scale. RN #540 confirmed Resident #34's pain during the treatment administration was severe and rated it as a seven to 10 on a scale of zero to 10 with 10 being the worst pain. RN #540 further confirmed Resident #34 had increased pain due to a fracture to her right ankle which was identified on 11/15/22 and pressure ulcers to her left foot which were identified on 11/16/22. RN #540 confirmed she did not assess Resident #34's pain prior to wound care, nor did she offer her pain medication or other interventions prior to wound care. RN #540 confirmed she was aware Resident #34 was in severe pain during wound care, but she continued to provide care and tried to work quickly because the resident was in pain. Interview on 12/01/22 at 4:22 P.M. with LPN #180 confirmed Resident #34 was not able to rate her pain using a numerical scale. LPN #180 confirmed Resident #34 had refused her routine dose of MS Contin at 8:00 A.M. on 12/01/22, and she had not observed the resident exhibiting any signs of pain during random observations of the resident throughout the day. LPN #180 confirmed Resident #34 had not received any pain medication on 12/01/22 prior to wound care at 4:08 P.M. Review of the facility policy titled Pain Clinical Protocol dated March 2018 revealed staff would use a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. The nursing staff would identify any situations or interventions where an increase in the resident's pain may be anticipated, for example, wound care, ambulation, or repositioning. Review of the NPUAP guidelines dated 2014 page 161 at https://npiap.com/general/custom.asp?page=2014Guidelines in the section regarding Pain Management for Residents with Pressure Ulcers revealed staff should organize care delivery to ensure that it is coordinated with pain medication administration and that minimal interruptions follow. Set priorities for treatment. Pain management includes performing care after administration of pain medication to minimize pain experienced and interruptions to comfort for the individual. Review of online resource at https://www.mdapp.co/pain-assessment-in-advanced-dementia-painad-scale-calculator-550/ revealed the Pain Assessment in Advanced Dementia Scale (PAINAD) scale was a reliable tool for pain evaluation in dementia patients. The original study defines scores between zero and 10, where zero means no pain and 10 means severe pain. The scale administrator is asked to observe the patient for five minutes, either at rest, during a relaxing activity, during caregiving activities or administration of pain medication. PAINAD items include descriptions of breathing (independent of vocalization), negative vocalization, facial expression, body language, and consolability.