**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of a facility fall report, policy review and interview, the facility failed to provide timely and necessary pain management (including the administration of effective pain medication) for Resident #23 following the identification of an injury to the resident's hip/leg. Actual Harm occurred on 05/19/24 when direct care staff identified Resident #23, who was severely cognitively impaired had increased incontinence (not his baseline) and verbal and non-verbal signs of pain including facial grimacing and grabbing his right leg during care resulting in unrelieved pain. On 05/19/24 at 11:16 A.M. nursing staff received an order for Ultram for pain. However, the medication was not administered on this date until 4:05 P.M. (almost five hours after the order was received). The resident was subsequently transferred to the emergency room on 0519/24 at 8:32 P.M. for treatment of a fractured right hip. This affected one resident (#23) of one resident reviewed for pain. The facility census was 44. Findings include: Review of the medical record for Resident #23 revealed an admission date of 08/19/23 with diagnoses including repeated falls, cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, vascular dementia with a new diagnosis of fracture of unspecified part of neck of right femur, initial encounter for closed fracture dated 05/29/24 during stay. Review of physician's order dated 08/19/23 at 12:45 P.M. Resident #23 revealed an order for Acetaminophen (Tylenol) 500 milligrams (mg) enterally every six hours as needed for pain. Review of quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #23 had severely impaired cognition and was rarely/never understood. The resident was assessed to require (staff) supervision or touching assistance with bed mobility, partial/moderate (staff) assistance with all transfers and substantial/maximal (staff) assistance with toilet hygiene. The assessment reflected Resident #23 had no falls during the look back period, was occasionally incontinent of urine and was continent of bowels. Review of the progress note dated 05/19/24 at 11:23 A.M. revealed Resident #23 was noted to be incontinent of urine which he was usually continent. The resident was holding his right leg up to his chest, and had bruises noted on right leg and right inner leg. The progress note revealed the resident was questioned if he fell and he shook his head yes. When asked when, the resident put his two fingers up. When asked two days ago, the resident shook his head yes. When asked if he got himself up, he shook his head yes. The progress note revealed the certified nurse practitioner (CNP) was notified, and an order was received for an x-ray of the hips, labs and for pain medication. Review of the progress note revealed no evidence a comprehensive pain assessment was completed at this time or evidence the facility attempted any type of non-pharmacological pain interventions for the resident. Review of the resident's nursing progress notes revealed no documentation of any type of fall sustained by the resident two days prior. There was no documentation of any type of injury or bruising to the resident's leg prior to this note on 05/19/24 . Further review of Resident #23's progress notes revealed no documentation of a pain assessment, no evidence Tylenol (for pain) was administered, and no evidence non-pharmacological pain interventions were completed. Review of Resident #23's medication administration record (MAR) for 05/19/24 revealed no documentation Tylenol was administered during the entire 24-hour period on this date. Review of a physician's order dated 05/19/24 at 11:43 A.M. revealed an order for Ultram (a narcotic-like pain reliever) 50 mg one tablet every eight hours as needed for pain. Orders were also written (at 11:45 A.M.) for an x-ray two view bilateral hips for pain related to hip and questionable fall. There was no indication the resident was provided any pharmacological or non-pharmacological pain interventions at this time. Record review revealed between 11:23 A.M. and 4:05 P.M. the facility failed to monitor the resident's pain or provide pain management. Record review revealed on 05/19/24 at 4:05 P.M. (almost five hours after the order was received) Resident #23 was administered Ultram 50 mg for what staff documented was pain rated a four on a scale of 0 to 10 with 10 being the most severe pain. Review of the progress note dated 05/19/24 at 6:57 P.M. revealed the two-view x-ray of the right hip was completed. Left hip x-ray not done due to the resident not being able to tolerate laying on his left side. CNP notified. Review of Resident #23's x-ray results dated 05/19/24 revealed the right hip demonstrated a slightly displaced fracture of the right femur in the sub capital portion. Review of the progress note dated 05/19/24 at 8:32 P.M. revealed facility staff called 911 to get Resident #23 transferred to nearest available emergency room. Resident #23 had confirmed results of fractured/broken right hip. Review of the discharge return anticipated Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 had severely impaired cognition. The assessment noted Resident #23 received as needed pain medication. The assessment revealed the resident was unable to be understood, pain was determined by grimacing, groaning and guarding body part. Resident had one fall with major injury. Review of a progress note dated 05/23/24 at 10:39 A.M. written by Licensed Practical Nurse (LPN) #45 revealed Resident #23 was readmitted to the facility from a local hospital with a diagnosis of femur head fracture. The family refused to allow any surgical intervention. Review of the most recent MDS 3.0 assessment dated [DATE] revealed the resident remained rarely/never understood. The resident was assessed to require (staff) supervision or touching assistance with bed mobility, substantial/maximal (staff) assistance with toilet hygiene and staff dependence on shower/bathe. This resident was noted to take an opioid for seven out of seven of the assessment days. This resident also had a fracture related to a fall in the six months prior to reentry. Interview on 07/24/24 at 9:57 A.M. with Registered Nurse (RN) #512 revealed he was the nurse assigned to Resident #23 and working on 05/19/24. The RN revealed he was assisting another resident, so LPN #442 addressed the concerns with Resident #23 as well as calling the CNP to get orders. The RN revealed throughout his shift, Resident #23 had a flat effect but did not think the resident had verbal indicators of pain directly to him; however, the State Tested Nursing Assistant (STNA) staff working with the resident did come to him to inform him of the resident's pain during incontinence care. The RN was unable to recall the times staff reported the resident's pain to him and verified he did not implement any non-pharmacological interventions during the day. The resident was transferred to the emergency room that evening and was treated for a hip fracture. The RN was unable to recall what pain medication was provided to the resident and was also unable to recall most events for this shift. Interview on 07/24/24 at 10:33 A.M. with STNA #332 revealed she was assigned to work the hall Resident #23 was on and was working the day of 05/19/24. The STNA stated, I had to assist STNA #537 several times to clean up Resident #23 as he was incontinent and in bed and you could see on his face, he was not comfortable. We cleaned him up every two hours and for the first couple of changes, he would shake his head yes to being in pain and would resist rolling and being cleaned up. I told RN #512 as did STNA #537 and it wasn't until the early evening he wasn't as resistive to care but was still in pain. The STNA revealed no non-pharmacological pain interventions were attempted for the resident when staff were providing incontinence care. Interview on 07/24/24 at 10:50 A.M. with STNA #537 revealed she was assigned to work the hall Resident #23 was on and was working the day of 05/19/24. The STNA stated, I had to get STNA #332 to assist me to do incontinence care on him as he would make faces and hold his right leg and make sounds. He is usually continent, and I never need anyone to help me with him, so I knew something was wrong with him when we would do our changes every two hours. I reported this to RN #512 several times that he was in pain because I would ask him as well and he would shake his head yes to being in pain. The STNA verified no non-pharmacological pain interventions were attempted by staff when they were providing incontinence care. Interview on 07/24/24 at 11:25 A.M. with LPN #442 revealed on 05/19/24 she was not the nurse on Resident #23's hall, but stated she had responded after being told the resident was on his floor mat . The LPN revealed she assessed the resident and stated he was definitely in pain at the time, I didn't ask him what his pain was, but he was grimacing and holding his right leg to his chest and would not let us touch him, it was hard to get him back into bed. The LPN revealed no immediate non-pharmacological interventions were attempted at this time, other than placing the resident back in bed and calling the doctor. The LPN revealed she also told RN #512 the resident was in pain as the resident resided on the hall the RN was assigned for the shift. Interview on 07/24/24 at 2:59 P.M. with the Director of Nursing (DON) revealed on 05/19/24, a pain assessment should have been completed with the incident report completed for Resident #23 at the time of the incident. The DON verified the resident was not provided any of the ordered Tylenol as noted on the administration record. The DON also verified the lack of timely and effective pain management (pharmacological and non-pharmacological) during the shift as noted above. The DON verified the resident was transferred to the emergency room after x-ray results showed the hip fracture. The DON revealed the expectation of the nursing staff was to implement both pharmacological and non-pharmacological pain interventions when pain was indicated. Attempts to interview Resident #23 related to the incident and/or pain during the investigation were unsuccessful due to the resident's cognitive status. Attempts to reach the resident's wife were also unsuccessful. Review of the facility policy titled Pain Assessment and Management revealed acute pain should be assessed every 30 to 60 minutes after the onset and reassessed as indicated until relief was obtained. The pain management interventions shall be consistent with the resident's goal for treatment. Such goals would be specifically defined and documented. Non-pharmacological interventions may be appropriate alone or in conjunction with medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review, policy review, and interview, the facility failed to ensure Resident #22 was free from significant medication errors. This affected one resident (#22) of four residents reviewed for unnecessary medications. The facility census was 44. Actual Harm occurred on 11/27/23 and continued through 01/29/24 when the facility failed to clarify medication orders with Resident #22's referring hospital and include the resident in an admission care plan meeting, resulting in chemotherapy medication being administered in error to Resident #22. As a result of the medication errors, Resident #22 reported and suffered increased weakness, pain, nausea, constipation, and weight loss. Findings included: Closed record review revealed Resident #22 was admitted to the facility on [DATE] with diagnoses including paroxysmal atrial fibrillation, syncope and collapse, chronic systolic congestive heart failure, abdominal aortic aneurysm without rupture, malignant neoplasm of larynx, malignant neoplasm of liver, and malignant neoplasm of esophagus. Review of a paper copy of hospital notes dated 12/02/22 through 11/27/23 revealed the hospital's medication administration record (MAR) for Resident #22's stay from 11/24/23 through 11/27/23 did not indicate Capecitabine was an active medication. An additional medication list was provided with the dates 12/02/22 through 11/27/23 with Capecitabine listed but did not specify if it was a current order. Review of referral paperwork from the hospital dated 11/27/23 and scanned into the electronic medical record revealed an active medication list which did not include any chemotherapy medication. Additionally, a physician progress note was included dated 11/16/23 stating Resident #22 had a history of liver cancer and a history of esophageal cancer which had been treated and was in remission. Review of a fax from the Veterans Affairs on 11/29/23 revealed an updated medication list was sent to the facility for Resident #22 and had no indication Resident #22 was supposed to received any chemotherapy medication. Review of an admission history and physical completed by Physician #141 revealed hospital admission and discharge paperwork was reviewed and indicated Resident #22 had a history of liver and esophagus cancer. Review of a care plan dated 11/28/23 revealed no indication Resident #22 had a diagnosis of cancer or was receiving chemotherapy. Review of a Baseline Care Plan Review assessment dated [DATE] revealed no indication Resident #22 or a representative was invited to or participated in care planning meeting. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22's cognition was intact, he had no behaviors, had an active diagnosis of cancer and had received chemotherapy. Resident #22 discharged from the facility on 01/29/24. Review of a medication order summary revealed Resident #22 had an order dated 11/27/23 for Capecitabine (a chemotherapy medication) oral tablet 500 milligrams (mg) to give 1000 mg by mouth two times a day for 14 days on and seven days off for cancer treatment. The resident had an order dated 12/18/23 for Capecitabine oral tablet 500 mg give 1000 mg by mouth two times a day 14 days on and 7 days off for cancer treatment dated 12/18/23 (started on 12/26/23). Review of a medication administration record (MAR) for November 2023 revealed Capecitabine was administered 11/28/23 through 11/30/23. Review of the December 2023 MAR revealed Capecitabine was administered 12/01/23 through 12/18/23, stopped from 12/18/23 through 12/15/23, and administered from 12/26/23 through 12/31/23. Review of the January 2024 MAR revealed Capecitabine was administered from 01/01/24 through 01/08/24, stopped from 01/09/24 through 01/15/24, and started from 01/16/24 through 01/29/24. Review of November 2023 MAR revealed Resident #22 had an as needed (PRN) order started on 11/27/23 for acetaminophen oral tablet 500 mg give one tablet by mouth every 24 hours as needed for pain which was not administered. Review of December 2023 MAR revealed Resident #22 received a dose of acetaminophen on 12/10/23 with a pain level of 4, a dose on 12/11/23 with a pain level of 5 and then acetaminophen was discontinued on 12/13/24. A new order was given on 12/13/23 for Oxycodone HCI oral tablet 5 mg give one tablet by mouth for pain every 8 hours as needed for pain which was administered on 12/13/23 with a pain level of 6 at 4:05 P.M., 12/14/23 for pain level of 7 at 7:58 P.M.; 12/15/23 for a pain level of 5 at 11:47 P.M.; twice on 12/16/23 for pain levels of 5 at 11:26 A.M. and 2 at 9:11 P.M.; 12/17/23 for a pain level of 2 at 8:38 P.M.; on 12/18/23 three times with a pain level of 5 for each administration at 3:05 A.M., 9 A.M., and 9:04 P.M.; 12/20/23 with a pain level of 5 at 8:38 P.M.; 12/21/23 with a pain level of 6 at 8:04 P.M.; 12/23/23 with a pain level of 4 at 2:41 A.M.; 12/24/23 with pain levels of 5 at 11:33 A.M. and 8 at 7:33 P.M.; 12/25/23 with a pain level of 2 at 8:27 P.M.; 12/26/23 with a pain level of 2 at 11:45 P.M.; 12/27/23 with a pain level of 5 at 8:54 P.M.; and on 12/31/23 with a pain level of 2 at 6:58 P.M. Review of January 2024 MAR revealed Oxycodone was administered on 01/01/24 with a pain level of 3 at 7:45 P.M.; on 01/02/24 with a pain level of 5 at 2:19 P.M.; on 01/04/24 with a pain level of 4 at 8:01 P.M.; on 01/05/24 with a pain level of 5 at 7:50 P.M.; on 01/06/24 with a pain level of 5 at 7:14 P.M.; on 01/09/24 with a pain level of 7 at 7:52 P.M.; on 01/11/24 with a pain level of 2 at 9:29 P.M.; on 01/12/24 with a pain level of 0 at 7:46 P.M.; on 01/13/24 with a pain level of 5 at 8:13 A.M.; on 01/14/24 with a pain level of 4 at 7:28 P.M.; on 01/15/24 with a pain level of 6 at 8 P.M.; on 01/17/24 with a pain level of 7 at 8:16 P.M.; on 01/18/24 with a pain level of 0 at 11:32 P.M.; on 01/19/24 with a pain level of 6 at 8:15 P.M.; on 01/20/24 with a pain level of 4 at 8 P.M.; on 01/22/24 with a pain level of 2 at 9:39 P.M.; on 01/23/24 with a pain level of 5 at 8:34 P.M.; on 01/24/24 with a pain level of 6 at 7:50 P.M.; on 01/25/24 with a pain level of 5 at 8:15 P.M.; on 01/26/24 with a pain level of 4 at 9:14 P.M.; on 01/27/24 with a pain level of 6 at 9:02 A.M. and 4 at 8:17 P.M.; and on 01/28/24 with a pain level of 4 at 7:53 P.M. Interview on 05/03/24 at 1:49 P.M. with Licensed Practical Nurse (LPN) #137 revealed she was not aware of any medication administration errors in the last six months. LPN #137 stated the floor nurse who was receiving the resident from the hospital would be responsible for entering orders upon admission. LPN #137 stated if an order was not clear, it should be clarified with the hospital, facility they came from, or the in-house physician who would be taking of the care of the resident. LPN #137 stated if a resident made her aware they were receiving a medication they were not supposed to receive, she would call the hospital to get the order clarified. Interview on 05/03/24 at 2:06 P.M. with LPN #156 revealed the nurse who received a resident would be responsible for entering medication orders into their chart. LPN #156 stated if an order received from the hospital was not clear, she would call the hospital to get the order clarified. LPN #156 revealed she became aware of Resident #22's medication errors after he was already discharged (from the facility in January 2024) when the facility was notified by the Veterans Affairs (VA) called after reviewing Resident #22's discharge information from the facility. Interview on 05/03/24 at 2:32 P.M. with Resident #22 revealed his chemotherapy medication had been discontinued approximately seven years ago after his cancer was in remission. Resident #22 stated he was not aware of what medications he was receiving in the facility and he had not been invited to participate in an admission care plan meeting to review the baseline care plan, medication list, or set goals for his stay at the facility. Resident #22 stated when he returned to his home, he received a call from the VA to inform him he had been taking chemotherapy medication after they reviewed the paperwork the facility sent them regarding Resident #22's stay. Resident #22 stated he had to start taking pain medications while he was at the facility due to increased pain, which he suspected was related to taking the chemotherapy medication. Resident #22 stated other side effects from the chemotherapy included nausea, constipation, weakness, loss of appetite and taste, and weight loss. Resident #22 stated he had a hard time getting up, he was staggering and required the use of a walker and would now have to start physical therapy again to regain some strength. Interview on 05/03/24 at 2:46 P.M. with Home Health Aide (HHA) #145 revealed while Resident #22 was at the facility, she had come to visit and the facility informed her Resident #22 had cancer and would not likely be leaving the facility. HHA #145 stated since leaving the facility, Resident #22 was more short-tempered, nauseated, sick to his stomach, weak and didn't eat like he used to. HHA #145 stated when Resident #22 admitted to the facility, he weight 230 pounds and was now down to 202 pounds, which was a 12.93% weight loss in two months. Interview on 05/03/24 at 3:33 P.M. with the Director of Nursing (DON) revealed she was unable to confirm if the chemotherapy medication listed on the hospital referral dated 12/02/22 through 11/27/23 was an old order but stated it was reasonable to assume it was a current order. The DON stated the referral information faxed from the hospital on [DATE] with a medication list dated 11/27/23 that did not contain chemotherapy would not be a reliable source for medication orders because often times, those orders were outdated. The DON confirmed the history and physical in the hospital paperwork specified Resident #22 had a history of liver and esophageal cancer which had both been treated and were currently in remission. The DON stated since the facility received the order for chemotherapy, it was not her place to determine if Resident #22 should have received the medication. The DON confirmed none of the nurse practitioners or physicians who treated Resident #22 while at the facility were cancer specialists. The DON confirmed the baseline care plan meeting did not indicate Resident #22 or family were invited or in attendance. DON confirmed medications, care plan and goals would be reviewed at baseline care plan meetings. DON confirmed Resident #22 was alert and oriented, and would have been able to tell staff he should not have been taking chemotherapy if he had been given the chance to participate in a care plan meeting. DON also confirmed if the order for chemotherapy had been accurate, the order stated medication should be given twice daily for 14 days, then held for 7 days, and medication had been administered from 11/27/23 through 12/18/23 which added up to 22 days the medication was administered without a seven-day break. Interview on 05/03/24 at 4:46 P.M. with the Administrator confirmed Resident #22 was admitted to the facility with orders for PRN acetaminophen 500 mg which were not administered until 12/10/23 and 12/11/23, then was discontinued and a new order for PRN Oxycodone 5 mg was given for increased pain. The Administrator confirmed there was no evidence Resident #22 was invited to, attended the admission care plan meeting, or provided with a baseline care plan. Interview on 05/03/24 at 5:09 P.M. with Administrator confirmed the VA sent an updated medication list to the facility on [DATE], two days after Resident #22 admitted to the facility, and did not include chemotherapy. Interview on 05/09/24 at 9:23 A.M. with VA Privacy Officer #202 revealed Nurse Practitioner (NP) #201 was interviewed on 05/09/24 at 8:33 A.M. regarding Resident #22's symptoms being related to the chemotherapy medication. NP #201 stated Resident #22 was admitted to rehab and during the time he was receiving chemotherapy medications. Resident #22 was at the end of the 14 days off cycle for the chemotherapy pill when he came back to us at Homebase Primary Care through the VA Medical Center. He was taken off the chemotherapy drug approximately four years ago, and we realized he received the medication during his stay at the facility after reviewing his discharge records. Other medication Resident #22 had received during his stay at the facility included Percocet for hip and bone pain, Pepcid and Prilosec for acid reflux. Resident #22 reported poor taste, bitterness of food and increased heart burn. In reviewing the side effects of the drug, all his side effects including pain, heart burn, poor taste, poor appetite, and weight loss were distinct possibilities as side effects from receiving the chemotherapy drug. Review of a policy titled Administering Medications dated April 2019 revealed medications are to be administered in accordance with prescriber's orders, if a dosage is believed to be inappropriate or excessive for a residents or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse effects the person preparing or administering the medical will contact the prescriber to discuss concerns. Review of a policy titled Care Plans- Baseline dated December 2016 revealed a baseline plan of care to meet the resident's immediate needs shall be developed for each resident within 48 hours of admission, the interdisciplinary team will review the healthcare practitioner's orders, and implement a baseline care plan to meet the resident's need including but not limited to initial foals based on admission orders, physician orders, dietary orders, therapy services, social services. The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan. The resident and their representative will be provided with a summary of the baseline care plan that includes the initial goals of the resident, a summary of the resident's medications and dietary instructions, any services and treatments to be administered by the facility and personnel acting on behalf of the facility, and any updated information based on the details of the comprehensive care plan as necessary. Review of a policy titled Reconciliation of Medications on Admission dated July 2017 revealed To prepare for medication reconciliation, gather the information needed to reconcile the medication list including the approved medication reconciliation form, discharge summary from the referring facility, admission order sheet, all prescription and supplement information obtained from the resident or family during the medication history, and the most recent medication administration record for readmissions. Reconciliation of medications is completed to ensure an accurate medication list and includes the drug name, dosage, frequency, route of administration, and the purpose of the medication. This helped to reduce medication errors and enhances resident safety. Medication reconciliation helps to ensure all medications, routes, and dosages on the list are appropriate for the resident and their condition, and do not interact in a negative wat with other medications or supplements on the list. Medication reconciliation also ensures correct medication information is communicated to the attending physician and care team. If medication information is not collected from the resident or family, ask the resident to list all physicians and pharmacies from which they obtained medications. The list should be reviewed carefully to determine any discrepancies or conflicts. If the dose on the discharge medication list does not match the resident's previous MAR or there is a potential medication interaction this could be a discrepancy. If there is a discrepancy, contact the nurse from the referring facility, contact the physician from the referring facility, discuss with the resident or family, contact the resident's primary care physician, contact resident's pharmacy or contact the admitting physician. Document any discrepancies on the medication reconciliation form, the actions taken to resolve the discrepancy, if left unresolved how the information was communicated to the next nurse, and if resolved document how it was resolved. This deficiency represents non-compliance investigated under Complaint Number OH00153086.