**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record reviews, and facility policy review, the facility failed to ensure that pain management was provided for 1 Resident(R88) of 3 residents reviewed for pain. Specifically, the facility failed to provide R88 pain medication the resident had requested after a fall. This failure resulted in R88 being in pain for approximately six hours, from the time of their fall to the time they received pain medication. The resident's pain limited R88's ability to participate in activities of daily living (ADLs) and the resident was heard crying out in pain. Findings included: A review of a facility policy titled, Pain Management, reviewed in March 23, revealed, The goal of pain management is patient control of interventions for pain relief. The patient is the authority on their comfort and quality of life. Our goal is to promote comfort, independence, and socialization. Further review of the policy revealed, The onset of any new behavior or change in routine needs to alert the nurse to assess the patient more closely. Communication and interventions are important for quality patient care. A review of a Resident Face Sheet revealed the facility admitted R88 with diagnoses that included anxiety disorder, wedge compression fracture of the thoracic vertebrae, chronic pain, polyneuropathy, rheumatoid arthritis, and osteoarthritis. A review of the admission Minimum Data Set (MDS), dated [DATE], revealed R88 had a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. The pain assessment interview indicated the resident reported no pain within the previous five days. A review of R88's Care Plan indicated the resident had a problem category of Pain with a problem start date of 02/22/23, related to rheumatoid arthritis, osteoarthritis, compression fracture, and neuropathy. The facility developed an intervention that instructed staff to assess the resident for pain and intervene as indicated. A review of an Observation Detail List Report, completed by Occupational Therapist (OT) #1, with an Observation Date of 04/04/23 at 7:54 AM, indicated that OT1 was walking down the hallway and heard R88 yelling, Help. R88 was observed on the floor, and there were three certified nursing assistants (CNAs) already in the resident's room. The report indicated a nurse was called to the resident's room, and the staff picked the resident up off the floor and put the resident back in bed. OT1 assisted the resident with positioning. R88 said their right hip and left hand/forearm were hurting after the fall and requested acetaminophen for the pain. During the initial tour of the facility on 04/04/23 at 1:50 PM, R88 was heard crying out and was observed lying in bed with a pillow under their right knee. During an interview at that time, R88 stated they had fallen that morning and thought their leg had been broken. In an interview on 04/04/23 between 1:50 PM and 2:00 PM, Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #1 stated R88 had fallen that morning. LPN1 stated the doctor had been notified, and the facility was waiting on the mobile X-ray provider to arrive to complete an X-ray. LPN1 stated she was just in the resident's room and the resident did not complain of pain but would provide the resident with some pain medication. On 04/04/23 between 1:50 PM and 2:00 PM, LPN1 entered R88's room with a medication cup and stated it was the resident's pain medication. Review of a Medication Administration Record (MAR) for April 23 indicated R88 had a physician's order, with a start date of 03/08/23, for acetaminophen 325 milligrams (mg), two tablets as needed every six hours for general discomfort. The MAR revealed that on 04/04/23 at 1:52 PM, LPN1 administered 650 mg of acetaminophen to R88. The MAR indicated R88 had rated their pain a 6 on a scale of 0 to 10. The MAR indicated R88 had received no pain medication on 04/04/23 prior to the administration of acetaminophen at 1:52 PM. During an observation on 04/04/23 at 2:07 PM, the Assistant Director of Nursing (ADON) was in Resident 88's room with two CNAs providing incontinent care for the resident. R88 began to cry out in apparent pain loudly enough to be heard in the hallway. Review of an Occupational Therapy Treatment Encounter Note(s), dated 04/04/23 at 2:23 PM and signed by OT1, indicated OT1 provided services to R88 on 04/04/23. The note indicated R88 fell that morning, and OT1 had assisted with getting R88 back in bed after the fall. The note indicated that during the therapy session, R88 had increased pain in their shoulders and right hip, as well as increased pain with movement from rolling left to right in bed. The note indicated R88 had pain that was exhibited by clenched teeth, facial grimacing, holding the area of pain, heavy breathing, and rubbing the area of pain. The note indicated the pain limited R88's bed mobility and activities of daily living (ADLs). The note also indicated moving around after the fall exacerbated R88's pain. In a Progress Note, dated 04/04/23 at 2:33 PM, Medical Doctor (MD) #1 documented he was called and notified of R88's fall, the resident complained of right hip pain after the fall, and X-rays had been ordered. During an interview on 04/04/23 at 2:51 PM, R88 was lying in bed and could not recall how the fall occurred that morning. The resident appeared confused, and a thorough interview was not completed due to the resident's cognitive status. Review of an Event Report completed by LPN1, with an Event Date of 04/04/23 at 3:05 PM and a Completed Date of 04/04/23 at 3:12 PM, revealed LPN1 indicated that R88 had a fall and was found on the floor in the resident's room. The report indicated the resident complained of pain in their right hip after the fall and rated the pain a 3 on a scale of 0 to 10. The report further indicated a range of motion assessment was completed without pain, and the physician was notified of the fall on 04/04/23 at 3:15 PM. Review of a Progress Note dated 04/04/23 at 7:47 PM and signed by LPN1, revealed LPN1 was summoned to R88's room by staff, and R88 was observed lying on the floor on the resident's right buttock. R88 stated they wanted to go home. LPN1 completed a range of motion assessment, and the resident stated they felt a little pain, but it was not too bad. R88 was assisted back to bed and the MD was notified. The note did not indicate the time of the MD notification. During an interview on 04/05/23 at 1:21 PM, LPN1 stated R88 had an unwitnessed fall the morning of 04/04/23 but could not recall the time, stating she thought it occurred between 9:00 AM and 11:00 AM. LPN1 stated CNA1 went into the resident's room to provide care, and the resident was found on the floor, lying on the resident's right side. LPN1 stated a therapist, CNA1, and possibly two other staff members were in the resident's room. LPN1 stated the facility's policy required staff to notify the doctor and the family after a resident had a fall and that she notified the resident's family member and MD1 during MD1's morning rounds the morning of the fall. LPN1 stated MD1 asked if the resident was in any pain, and LPN1 reported the resident had minimal pain on the resident's right side. LPN1 stated she talked to MD1 after he left the facility and notified MD1 the resident was complaining of pain and asked if she could order an X-ray. LPN1 stated the X-ray was ordered in the afternoon but could not recall the time. LPN1 stated the resident complained of pain mid-morning after the fall when a CNA attempted to provide care to the resident, and the resident did not want staff to roll the resident over in the bed for the care to be provided. LPN1 stated she provided R88 with acetaminophen after the surveyor notified LPN1 of the resident's pain and had not provided the resident with any pain medication prior to that time on 04/04/23. LPN1 clarified her documentation in the Progress Note of 04/04/23 at 7:47 PM, stating the fall occurred the morning of 04/04/23, and the time on the note was when she was able to sit down to chart on the resident. LPN1 stated, Yesterday was so crazy. I had a lot going on yesterday morning. During an interview on 04/06/23 at 10:52 AM, MD1 stated the facility did not notify him of the fall that occurred on 04/04/23 until 2:30 PM. MD1 stated staff told him R88 had pain after the fall and the nurse had already put in an order for the X-ray. MD1 stated if a resident fell, staff should notify him right away if there were any injury or pain. MD1 stated he was in the facility the morning of the fall, and nobody notified him until that afternoon. During an interview on 04/05/23 at 2:21 PM, OT1 stated that on 04/04/23, before 8:00 AM, she was walking down the hall and heard R88 saying, Help. OT1 went into R88's room and the resident was lying between the wall and the bed, with the resident's head near the foot of the bed. OT1 stated there were three CNAs in the resident's room, and they waited for LPN1 to assess the resident. OT1 stated she was not sure if the resident received any pain medication, but LPN1 had told OT1 that she was going to give the resident acetaminophen for the pain. OT1 stated she saw the resident later that morning for therapy and stated the resident was hurting and the exercises were really, really painful. The resident told OT1 that the resident had pain everywhere, which was not typical for the resident, and the resident was in a lot more pain than normal. OT1 stated she did not report the pain to anyone because she knew the resident had fallen that morning. During an interview on 04/05/23 at 2:46 PM, CNA1 stated she was one of the staff members in R88's room after the resident fell. She stated CNAs #2, #3, and #4, and LPN1 were in the resident's room. CNA1 stated the resident complained of pain in the right leg. During an interview on 04/06/23 at 10:05 AM, CNA2 stated that on 04/04/23, at approximately 7:30 AM, R88 yelled for help. CNA2 stated that she, CNA4, OT1, and LPN1 went into the resident's room and found the resident on the floor in their bedroom. CNA2 stated the resident complained of pain after the staff members picked the resident up and put the resident back in bed. During an interview on 04/06/23 at 10:22 AM, CNA3 stated that the morning of 04/04/23, a staff member called her into R88's room, and the resident was found on the floor, on the resident's right side. CNA3 stated there were three or four staff members in the resident's room. CNA3 stated the resident complained of pain in the resident's right side and in their leg. CNA3 stated R88 always complained of pain in their right leg, but the resident appeared to be in more pain than normal. During an interview on 04/06/23 at 10:39 AM, CNA4 stated R88 fell the morning of 04/04/23, sometime before breakfast. CNA4 stated she heard the resident yell for help and she and CNA2 were in the hall by the nurse's desk. When they arrived at the resident's room, the resident was found on the floor. CNA4 stated she left the room and notified LPN1, and OT1 was in the hallway, so she assisted, as well as CNA3. CNA4 stated LPN1 assessed the resident and asked if the resident was in any pain, and the resident stated their hip was hurting. CNA4 stated OT1 said the resident always complained about pain in their hip. CNA4 stated the resident appeared to be in more pain than normal after the fall. CNA4 stated that afternoon after the fall, it took her, CNA2, and the ADON to change the resident's brief because it hurt the resident to slide the brief underneath the resident and to move the resident's leg. The resident was crying out in pain. CNA4 stated she did not know if the resident had received any pain medication at that time. CNA4 stated they gave the resident breaks during care and R88 would tell the staff when they could continue. CNA4 stated she had never had any issues with changing the resident's brief before. During an interview on 04/07/23 at 11:08 AM, the Director of Nursing (DON) stated that after a resident fell and complained of pain, staff should notify the MD, Unit Manager, and DON immediately after the resident had been stabilized. The DON stated if a resident had pain beyond their baseline pain and requested pain medication, staff should notify the MD and get further orders, or if the resident had an as-needed (PRN) pain medication, it should be given. An interview was not conducted with the Administrator due to the Administrator not being present during the survey.