Based on record review and staff interview, it has been determined that the facility failed to ensure a resident's drug regimen is free from unnecessary drugs for 1 of 1 resident reviewed for adverse medication reactions, Resident ID # 36. Findings are as follows: Review of a facility policy titled, Allergy Notification dated 9/25/2018, states in part, Harmful unintended reactions to medicines, foods and to items in the environment are called adverse drug, food or environmental reactions or allergic reactions .To help ensure that adverse allergy reactions for a resident are not overlooked, the allergy design within the EMR [Electronic Medical Record] provides a structured format for users to document and monitor resident allergies .The allergies will be listed on the front cover of the medical record or computerized listing will be available in the medical record for reference . Record review revealed that Resident ID #36 was admitted to the facility in December of 2022 with diagnoses including, but not limited to, history of urinary tract infections (UTIs) and dysuria (painful urination). Review of a community report complaint received by the Rhode Island Department of Health on 9/21/2023 alleges that Resident ID #36 was treated with an antibiotic, Invanz (Ertapenem Sodium) for a UTI from 9/2/2023, 9/6/2023, and by 9/7/2023 the resident had confusion and hallucinations. Additionally, the allegation revealed that the resident had received the same antibiotic previously with a similar reaction of confusion and hallucinations. The antibiotic had not been added to the resident's allergy list to alert the provider or pharmacy of the adverse reaction. Review of the Highlights of Prescribing Information for Invanz by Merck Pharmaceuticals revealed rare adverse reactions including, altered mental status, such as aggression, delirium, and hallucinations. Review of the February 2023 Medication Administration Record (MAR) revealed the resident received INVanz Solution Reconstituted 1 GM [gram] (Ertapenem Sodium, antibiotic) Inject 1 gram intramuscularly [IM] one time a day for infection for 7 Days from 2/22-2/25/2023. Review of the progress notes from February 2023 revealed the following: 2/23/2023 at 2:16 PM: .Pt [patient] shows apprehension towards IM antibiotic but allowed to be given on L [left] upper arm . 2/26/2023 at 2:09 AM: Socially Inappropriate/Disruptive: Noisiness/ Screaming. Resisted Care: Resisted ADL [activities of daily living] care. Paranoid Behaviors: Suspiciousness/ Fearfulness. Paranoid Behaviors: Hallucinations - Details of hallucinations: Seeing children in room. stated that they came out of [his/her] gut calling out names and yelling hello . 2/26/2023 at 5:33 AM: Pt refusing care this am. Insisting on sitting on side of bed. Demanding to get in chair but when approached to assist refuses assistance. Pt hallucinating 'bats all over [his/her] room and two babies sitting on the end of [his/her] bed . 2/26/2023 at 8:46 AM: Res [resident] continues with hallucinations this morning: Cats and dogs in room and two babies on the dresser. Called [sic] placed to covering MD [Medical Doctor], [name redacted], rec'd [received] n.o. [new order] .D/C'd [discontinued] Invanz. 2/27/2023 at 3:14 AM authored by the Physician, Staff C: Patient was reported to have some hallucination. Invanz IM discontinued . Record review of the September 2023 MAR revealed the resident received INVanz Solution Reconstituted 1 GM (Ertapenem Sodium) Inject 1 gram intramuscularly in the morning for UTI for 5 Days from 9/2/2023 until 9/6/2023. Review of the progress notes from September 2023 revealed the following: 9/8/2023 at 6:16 PM: Spoke with daughter [name redacted] about concerns of her [parent] being so confused and being alarmed there is no intervention being done about this. 9/10/2023 at 8:18 AM: Resident very restless, trying to get oob [out of bed] multiple times stating [s/he] wants to walk to the bathroom, also that [s/he] is going to the hospital for a test. staff tried to reorient and redirect [him/her] to stay in bed as [s/he] cannot ambulate the way [s/he] thinks [s/he] can, attempts unsuccessful. 9/11/2023 at 4:31 PM revealed that the nurse added Invanz to the resident's allergy list as the daughter indicated that the resident had a change in mental status after his/her last administration of the antibiotic. During a surveyor interview on 9/21/2023 at 2:21 PM with the resident's daughter, she revealed that the resident was having hallucinations following the administration of the Invanz and that the same had occurred when s/he received the medication previously in February. During a surveyor interview on 9/22/2023 at 9:55 AM with the resident, s/he revealed that s/he received an antibiotic to treat a urinary tract infection and it caused hallucinations. Additionally, s/he revealed that s/he had been told that the same reaction occurred when s/he took the same antibiotic at the beginning of the year. During a surveyor interview on 9/22/2023 at 11:10 AM with Licensed Practical Nurse (LPN), Staff D, she revealed that the resident was on Invanz for a urinary tract infection and was having bizarre hallucinations such as, his/her grandchild being under his/her bed, talking to the ceiling and to people that were not there. Additionally, Staff D revealed that the resident appeared to be suffering severe mental anguish and distress. Staff D revealed that she had remembered this behavior occurred once before during another treatment (February) for a UTI and when she looked up the medication, [s/he] had also been on Invanz at that time During a surveyor interview on 9/22/2023 at 10:44 AM with the Physician, Staff C, he revealed that he would not have ordered the same antibiotic if it had been marked on his/her medical record. During a surveyor interview on 9/22/2023 at 10:57 AM with the Interim Director of Nursing Services (DNS) she was unable to provide evidence that the facility ensured a resident's drug regimen is free from unnecessary drugs by administering a medication with a known previous adverse reaction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews it has been determined that the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for 1 of 1 resident reviewed for adverse medication reactions and following physicians' orders for specialist medical appointments, Resident ID #36 and 1 of 1 resident reviewed for Hospice Services, Resident ID #21. Findings are as follows: 1a. Review of a facility policy titled, Allergy Notification dated 9/25/2018, states in part, Harmful unintended reactions to medicines, foods and to items in the environment are called adverse drug, food or environmental reactions or allergic reactions .To help ensure that adverse allergy reactions for a resident are not overlooked, the allergy design within the EMR [Electronic Medical Record] provides a structured format for users to document and monitor resident allergies .The allergies will be listed on the front cover of the medical record or computerized listing will be available in the medical record for reference . Record review revealed that Resident ID #36 was admitted to the facility in December of 2022 with diagnoses including, but not limited to, history of urinary tract infections (UTIs) and dysuria (painful urination). Review of a community report complaint received by the Rhode Island Department of Health on 9/21/2023 alleges that Resident ID #36 was treated with an antibiotic, Invanz (Ertapenem Sodium) for a UTI from 9/2/2023, 9/6/2023, and by 9/7/2023 the resident had confusion and hallucinations. Additionally, the allegation revealed that the resident had received the same antibiotic previously with a similar reaction of confusion and hallucinations. The antibiotic had not been added to the resident's allergy list to alert the provider or pharmacy of the adverse reaction. Review of the Highlights of Prescribing Information for Invanz by Merck Pharmaceuticals revealed rare adverse reactions including, altered mental status, such as aggression, delirium, and hallucinations. Review of the February 2023 Medication Administration Record (MAR) revealed the resident received INVanz Solution Reconstituted 1 GM [gram] (Ertapenem Sodium, antibiotic) Inject 1 gram intramuscularly [IM] one time a day for infection for 7 Days from 2/22-2/25/2023. Review of the progress notes from February 2023 revealed the following: 2/23/2023 at 2:16 PM: .Pt [patient] shows apprehension towards IM antibiotic but allowed to be given on L [left] upper arm . 2/26/2023 at 2:09 AM: Socially Inappropriate/Disruptive: Noisiness/ Screaming. Resisted Care: Resisted ADL [activities of daily living] care. Paranoid Behaviors: Suspiciousness/ Fearfulness. Paranoid Behaviors: Hallucinations - Details of hallucinations: Seeing children in room. stated that they came out of [his/her] gut calling out names and yelling hello . 2/26/2023 at 5:33 AM: Pt refusing care this am. Insisting on sitting on side of bed. Demanding to get in chair but when approached to assist refuses assistance. Pt hallucinating 'bats all over [his/her] room and two babies sitting on the end of [his/her] bed . 2/26/2023 at 8:46 AM: Res [resident] continues with hallucinations this morning: Cats and dogs in room and two babies on the dresser. Called [sic] placed to covering MD [Medical Doctor], [name redacted], rec'd [received] n.o. [new order] .D/C'd [discontinued] Invanz. 2/27/2023 at 3:14 AM authored by the Physician, Staff C: Patient was reported to have some hallucination. Invanz IM discontinued . Record review of the September 2023 MAR revealed the resident received INVanz Solution Reconstituted 1 GM (Ertapenem Sodium) Inject 1 gram intramuscularly in the morning for UTI for 5 Days from 9/2/2023 until 9/6/2023. Review of the progress notes from September 2023 revealed the following: 9/8/2023 at 6:16 PM: Spoke with daughter [name redacted] about concerns of her [parent] being so confused and being alarmed there is no intervention being done about this. 9/10/2023 at 8:18 AM: Resident very restless, trying to get oob [out of bed] multiple times stating [s/he] wants to walk to the bathroom, also that [s/he] is going to the hospital for a test. staff tried to reorient and redirect [him/her] to stay in bed as [s/he] cannot ambulate the way [s/he] thinks [s/he] can, attempts unsuccessful. 9/11/2023 at 4:31 PM revealed that the nurse added Invanz to the resident's allergy list as the daughter indicated that the resident had a change in mental status after his/her last administration of the antibiotic. During a surveyor interview on 9/21/2023 at 2:21 PM with the resident's daughter, she revealed that the resident was having hallucinations following the administration of the Invanz and that the same had occurred when s/he received the medication previously in February. During a surveyor interview on 9/22/2023 at 9:55 AM with the resident, s/he revealed that s/he received an antibiotic to treat a urinary tract infection and it caused hallucinations. Additionally, s/he revealed that s/he had been told that the same reaction occurred when s/he took the same antibiotic at the beginning of the year. During a surveyor interview on 9/22/2023 at 11:10 AM with Licensed Practical Nurse (LPN), Staff D, she revealed that the resident was on Invanz for a urinary tract infection and was having bizarre hallucinations such as, his/her grandchild being under his/her bed, talking to the ceiling and to people that were not there. Additionally, Staff D revealed that the resident appeared to be suffering severe mental anguish and distress. Staff D revealed that she had remembered this behavior occurred once before during another treatment (February) for a UTI and when she looked up the medication, [s/he] had also been on Invanz at that time During a surveyor interview on 9/22/2023 at 10:44 AM with the Physician, Staff C, he revealed that he would have expected the staff to add the adverse medication reaction to the allergy list on the resident's face sheet. Additionally, he revealed that he would not have ordered the same antibiotic if it had been marked on his/her medical record. During a surveyor interview on 9/22/2023 at 10:57 AM with the Interim Director of Nursing Services (DNS), she revealed that she would have expected the adverse medication reaction to be added to the allergy list, to alert the physician and pharmacy to not order it. Additionally, she was unable to provide evidence that the facility provided treatment and care in accordance with professional standards of practice by administering a medication with a known previous adverse reaction. 1b. Record review revealed a physician's order with a start date of 3/10/2023 for a urology consult due to recurrent urinary tract infections. Review of a care plan for elimination revealed the resident has a history of UTIs with interventions including, but not limited to, urology consult as ordered. Review of a progress note dated 3/14/2023 at 11:10 AM revealed an appointment scheduled for a urology consult for 4/13/2023. Review of a progress note dated 4/5/2023 at 3:04 PM revealed the urology consult would be rescheduled to 6/26/2023. Record review revealed a fax cover sheet from the urology provider that states, We have no record that [s/he] was seen 6/26/2023. Record review failed to reveal evidence regarding the resident not attending his/her urology consult on 6/26/2023. Record review of a Lab Results Report dated 9/1/2023, revealed the resident was positive for a UTI. During a surveyor interview on 9/22/2023 at 10:44 AM with the Physician, Staff C he revealed that he was unaware that the resident did not attend his/her urology appointment and still wants the resident to have a urology consult. During a surveyor interview on 9/22/2023 at 11:36 AM with a Receptionist at the urology provider, she revealed that the resident was a no call, no show for the appointment and that no one from the facility or family cancelled the appointment. During a surveyor interview on 9/22/2023 at 10:57 AM with the Interim DNS, she was unable to provide evidence that the resident was seen by a urologist as ordered and per his/her care plan. 2. Record review revealed Resident ID #21 was admitted to the facility in March of 2020 with diagnoses including, but not limited to, unspecified dementia and generalized anxiety disorder. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9 out of 15, indicating moderately impaired cognition. Record review revealed the resident was admitted to hospice services in November of 2021. Review of the resident's care plan revealed a focus area dated 4/2/2020, which revealed the resident has the potential for mood alteration due to his/her diagnoses, and is evidenced by periodic tearfulness, anxious mood, restlessness, paranoid ideation, expressions of suicidal ideation or hopelessness, and medication refusals. Additionally, it was revised on 6/2/2023, to state, Ongoing anxious and restless mood observed. Not always easily redirected. Continue with current plan of care. Interventions include but are not limited to, document mood, behavior status, and changes to the physician as needed. Review of the resident's progress notes revealed a note dated 8/29/2023 which states, Behavior: Pt [patient] awake most of the night, rang call bell approx 20 times during the night, repeated questions 'Am I gonna die', 'Am I gonna live', 'What tests are they running on me'. Intervention : Multiple attempts to answer pt's questions and offer reassurance. Brought pt several glasses of gingerale and adjusted bedding nurmerous [sic.] times. Pt denied pain/disc. Response : Behavior continued, pt seemed paranoid, anxious, stating 'Let me see your face, are you telling the truth? I see your eyes, I think that's a lie'. Review of a document titled, HOSPICE CARE COORDINATION NOTE, dated 8/29/2023 states in part, .Spoke with .Floor staff who verbalize PT has been increasingly anxious, specifically at night where it keeps [him/her] up as [s/he] is fearful of dying in [his/her] sleep. Spoke with ADNS [Assistant Director of Nursing] who verbalized she is going to call MD [Medical Doctor] to reinstate Ativan [used to treat anxiety disorders] . Further review of the HOSPICE CARE COORDINATION NOTE dated 8/29/2023 revealed a recommendation to restart Ativan 0.5 milligrams every 12 hours, as needed, for anxiety and agitation. Further review of the resident's progress notes revealed a note dated 8/29/2023 which states, Resident seen by hospice RN [Registered Nurse] today. New recommendation to reinstate ativan 0.5mg [every 12 hours as needed] anxiety/agitation. ADON [Assistant Director of Nursing] reaching out to MD. Record review failed to reveal evidence that the recommendation for Ativan was addressed or implemented by the physician. Review of a behavior monitoring form dated 9/3/2023 at 8:55 PM, revealed the resident was displaying behavior symptoms such as, agitation restlessness, consistently picking or fidgeting with items or body parts, and repetitive babbling or perseverating on verbal phrases. It further revealed that non-pharmacological interventions were used, such as comfort visit and redirection, but were documented as being ineffective, with no change in behavior. Additionally, it revealed that no pharmacological intervention was used. Review of an additional behavior monitoring form dated 9/13/2023, revealed the resident was displaying behavioral symptoms on 9/13/2023 at 3:30 AM. S/he displayed behaviors such as restlessness and agitation, evidenced by the resident ringing his/her call bell for approximately two hours. Potentially contributing factors were documented as increased anxiety. It further revealed that non-pharmacological interventions were used, such as comfort visit, food or drink offered, and toileting but was documented as being ineffective, with no change in behavior. Additionally, it revealed that no pharmacological intervention was used. Review of the resident's behavior observation task revealed the following dates and times the resident displayed behaviors during the evening or night, following the recommendation for Ativan, such as verbal or physical aggression, social or sexually inappropriateness, withdrawn, anxiety, or refusal of care: - 9/2/2023 at 8:43 PM, documented as occurring more than once during the shift - 9/5/2023 at 9:37 PM, documented as occurring more than once during the shift - 9/7/2023 at 8:32 PM, documented as occurring more than once during the shift - 9/8/2023 at 8:52 PM, documented as occurring more than once during the shift - 9/15/2023 at 8:21 PM, documented as occurring more than once during the shift - 9/16/2023 at 7:41 PM, documented as occurring more than once during the shift - 9/18/2023 at 8:04 PM, documented as occurring more than once during the shift During a surveyor interview on 9/21/2023 at 10:23 AM, with LPN, Staff E, she revealed the resident is highly anxious and is very fixated on dying. She indicated these behaviors have been occurring for over a year and staff must constantly reassure him/her that death is not imminent. During a surveyor interview on 9/21/2023 at 10:53 AM, with the Physician, Staff F, she revealed that hospice recommendations are reported to the physician by the nursing staff. She indicated that the resident has displayed these behaviors in the past, but revealed she was not aware that the behaviors have returned. Additionally, she was unable to provide evidence that the hospice recommendation was addressed. During a surveyor interview on 9/21/2023 at 11:13 AM with the Interim DNS, she revealed that she was not aware of this recommendation and had not received it, prior to the surveyor bringing it to her attention. She further revealed that the resident and her family have refused Ativan in the past but was unable to provide evidence of any refusal or that the recommendation was addressed by the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review, resident, and staff interviews, it has been determined that the facility failed to ensure that pain management was provided to a resident who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 2 of 3 residents reviewed for pain management, Resident ID #s 46 and 257. Findings are as follows: Per the American Nurses Association (ANA) Statement The Ethical Responsibility to Manage Pain and the Suffering It Causes (2018): Nurses have an ethical responsibility to relieve pain and the suffering it causes; Nurses should provide individualized nursing interventions; The nursing process should guide the nurse's actions to improve pain management; Multimodal and interprofessional approaches are necessary to achieve pain relief . Review of a facility provided policy titled Pain Management dated 2/3/2023 states in part, .If the resident's pain is not controlled by the current treatment regimen, the practitioner should be notified . 1. Record review for Resident ID #257 revealed s/he was admitted to the facility in September of 2023 with diagnoses including, but not limited to, osteomyelitis (bone infection), pressure ulcer of the sacral region stage 4 (stage 4 pressure ulcer is the most severe type of pressure ulcer. The skin is severely damaged, and the surrounding tissue begins to die. The underlying muscles or bone may also be damaged), pressure ulcer of the right buttocks stage 4, and pressure ulcer of the left buttocks stage 4. Review of a Brief Interview for Mental Status conducted on 9/18/2023 revealed the resident scored a 15 out of 15 indicating the resident is cognitively intact. Review of the care plan dated 9/14/2023 revealed the resident has pain or potential in an alteration in comfort related to a chronic physical disability, right hip infection, and pressure ulcers. It further has interventions which include, but are not limited to, report non-verbal or verbal signs and symptoms of pain promptly to the nurse, medicate prior to therapy and treatment procedures as needed, teach resident to request analgesics/non-pharmacological methods before pain becomes severe and clarify misconceptions about addictions to pain medications. Review of the September 2023 Medication Administration Record (MAR) revealed the following orders: -Oxycodone HCl tablet 5 milligram (MG) give 5 mg by mouth every 12 hours as needed for pain with a start date of 9/13/2023. -Acetaminophen (Tylenol) tablet 325 MG give 2 tablets by mouth every 4 hours as needed for discomfort with a start date of 9/13/2023. Record review failed to reveal a pain scale indicating when to administer each medication. Review of occupational therapy documents dated 9/14/2023, revealed the residents pain limits his/her functional activities and s/he complained of 8 out of 10 pain to his/her right hip. It further revealed that the resident would like to be premedicated 1 hour prior to therapy related to his/her pain. Review of the physical therapy documentation dated 9/18/2023 revealed that the resident's treatment was limited by 7 out of 10 right hip pain. Review of the progress notes revealed the following: -9/14/2023 at 2:44 PM .[complaint of] 7/10 [right] hip and lower back pain. Assessed by therapy today. Therapy recommends bed pump and scheduling oxycodone prior to [physical therapy] daily. OK'd by Dr . -9/17/2023 at 11:53 PM authored by Registered Nurse (RN) Staff H, .Resident refused dressing changes this evening. Stated, 'I need to be medicated with oxycodone first so if you can't give me oxycodone then I'll wait till tomorrow when I can have some oxycodone before your [sic] change the dressings.' Unable to medicate resident with oxycodone [related to] time parameters . -9/18/2023 at 7:45 AM authored by RN Staff I, .Pt. [patient] also questioning why Oxycodone order is [every] 12 [hours] as well. Pt. wants to take pain med before Therapy and prior to Dressing changes, however yesterday [s/he] [received] pain med [at] 10am [and] refused [dressing] changes on 3-11 shift because Oxycodone could not be admin. until 10pm. Pt. requesting to speak [with] Dr. [name redacted] regarding [his/her] medications. Advised to write down all [his/her] concerns so [s/he] will not forget any when speaking w/ Physician. Suggested to Pt. about administering Oxycodone [at] 6am, then [s/he] could have it again [at] 6pm before [dressing] changes. Pt. declined stating [s/he] wants to take 1 hour before Therapy. Pt. presently [complaint of] 8/10 post-op [right] hip pain, offered Tylenol 650mg and ice and agreeable, 0600am admin. Tylenol, reports Tylenol ineffective . -9/18/2023 at 4:11 PM authored by the social worker Staff J, .Reports [his/her] concerns related to Oxycodone order, prefers every 6hrs [hours] vs 12hrs due to pain level throughout the day . -9/18/2023 at 6:22 PM Facility spoke with the nurse practitioner regarding this resident's labs. -9/19/2023 at 4:49 PM authored by the social worker Staff J, .patient requesting update on Oxycodone order. Writer explained this department would not be able to answer however as mentioned on 9/18, writer advised Nursing department this morning during morning report. Patient did not accept how the orders are handled within this facility and proceeded to refer to other hospitals/nursing facility standards. Patient expressed being dissatisfied with writer's answers. Writer attempted to advise again that the NP [Nurse Practitioner] will be in the facility on 9/20 and that she would be able to address concerns further . Record review revealed that the facility contacted the provider on 9/18/2023 regarding lab results; however, they did not report the resident not getting his/her dressings changed due to pain. Review of a pain interview completed on 9/19/2023 revealed that this resident had pain in the last 5 days. It further revealed that the pain is documented as occasionally. Additionally, the document revealed that pain has limited the resident's day to day activities. Lastly, at the time of the interview the resident's pain intensity was a 7 out of 10. During a surveyor interview with the resident on 9/18/2023 at 12:15 PM, s/he revealed concerns related to medication management, specifically his/her oxycodone timing. The resident revealed that s/he is in pain often and specifically needs his/her oxycodone prior to therapy and dressing changes. S/he further stated staff told him/her to write down his/her concerns and to talk to the doctor on Wednesday 9/20/2023. During a surveyor interview on 9/20/2023 at 9:07 AM with RN, Staff K, he revealed that the resident has osteomyelitis and skin grafts and that can be incredibly painful. He further revealed that he would not delay treatment saying to write something down on a Monday to be addressed on a Wednesday. During a surveyor interview on 9/21/2023 at 8:30 AM with Staff I, she revealed that in report she was told on Sunday night 9/17/2023 the resident refused to have his/her dressing changes completed to his/her wounds due to pain and not having a pain medication available. She further revealed that on the morning of 9/18/2023 she advised the resident to write down all of his/her concerns so s/he could address them with the provider when she comes in. Lastly, she revealed she did not contact the physician related to the resident refusing the dressing changes due to pain. During a surveyor interview on 9/22/2023 at 11:58 AM with RN, Staff H, she revealed that on 9/17/2023 she cared for the resident on the evening shift. She revealed that the resident wanted to be premedicated prior to his/her dressing changes. She indicated that when she checked the MAR the oxycodone was every 12 hours and told the resident to wait until 10 PM and then she could premedicate him/her to complete the dressings. The resident revealed that taking the medication at 10 PM and then completing the dressing changes would be too late. She further revealed that she did not contact the physician related to the resident's pain causing him/her to refuse the dressing changes. During a surveyor interview with the Physician, Staff F, on 9/21/2023 at 10:29 AM, she revealed that the facility did not call her, or the on-call provider related to the pain the resident was experiencing. Additionally, she revealed that if the facility reaches out to providers related to pain, typically the on call provider will give a one time dose if needed. Lastly, she revealed she would have expected them to call and ask for a one-time dose on 9/17/2023 so the dressing change could be completed. During a surveyor interview on 9/20/2023 at 1:42 PM, with the Interim Director of Nursing Services (DNS), she revealed that she would have expected the nursing staff to reach out to the provider to report the resident's pain and inability to complete the wound dressing due to pain. Furthermore, she was unable to provide evidence the facility provided pain management to a resident who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences resulting in the resident not receiving care of his/her stage 4 pressure wound dressings on 9/17/2023. 2. Record review revealed that Resident ID #46 was admitted to the facility in May of 2022 with a diagnosis including, but not limited to, polyosteoarthritis (present when four or more joints in the body are painful and inflamed). Review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 12 out of 15, indicating moderate cognitive impairment. Additionally, it revealed that the resident complained of occasional pain rating his/her pain a 6 out of 10. Review of a care plan dated 5/12/2022 revealed the resident has pain or has the potential for pain due to osteoarthritis. The care plan includes an intervention to report non-verbal or verbal signs and symptoms of pain promptly to the nurse and reassess and adjust plan to optimize pain relief as needed. Review of a progress note dated 9/17/2023 at 11:55 AM revealed, signs and symptoms of severe pain starting at lower back and affecting hips and bilateral lower legs. Unable to tolerate HOB [head of bed] elevated and sitting up to transfer. Reports pain subsides when not moving. Medicated with ES [extra strength] Tylenol and tramadol. Son in to visit and expressed concern regarding past back surgeries and requesting XRAYs. Awaiting orders from on call . Record review failed to reveal evidence of physician notification of increased pain. During a surveyor interview on 9/21/2023 at 9:58 AM with the resident in the presence of his/her son, s/he continued to complain of lower back pain radiating to his/her legs. During a surveyor interview on 9/21/2023 at 10:28 AM with Registered Nurse, Staff G, she revealed that the resident did complain of pain to his/her lower back that morning. Additionally, she revealed that she was unaware if x-rays had been performed or if the residents increased pain had been reported to the doctor. Review of a progress note dated 9/21/2023 at 12:40 PM stated in part, This writer spoke with [Doctor]. Pain management regime reviewed, New orders obtained for Aspercreme Patch Daily x 2 weeks to lower back; Resident has previously reported c/o [complaint of] pain to lower back, good effect or PRN [as needed] tramadol given. New orders obtained for X-RAY Spine . During a surveyor interview on 9/21/2023 at 1:01 PM with Licensed Practical Nurse (LPN), Staff D, revealed that the resident complained of increased pain on Sunday 9/17/2023 and stated that the pain was concerning. Additionally, she revealed that the resident was administered extra strength Tylenol without effect and Tramadol with little effect. Staff D, revealed that she did not report the change in pain to the doctor or request the x-rays that the resident and family requested. During a surveyor interview on 9/22/2023 at 10:44 AM with the Physician, Staff C, he revealed that the staff had not called him on 9/17/2023 to report an increase in back pain causing difficulty sitting up or transferring, until 9/21/2023, 4 days following the initial complaint. He indicated he did not receive communication regarding increased pain. During a surveyor interview on 9/21/2023 at 10:32 AM with the Interim DNS, she revealed that she would expect the nurse to call the doctor for new orders if a resident complains of increased pain. Additionally, she was unable to provide evidence that the facility provided pain management consistent with professional standards of practice and reporting a change in condition to the provider.