**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #238) of 6 residents reviewed for pain management. 1. The facility failed to ensure that Resident #238's pain was controlled for 11 days by not following physicians' orders regarding administration of hydrocodone. 2. The facility failed to ensure that Resident #238's pain was controlled for 5 days by not administering hydrocodone and fentanyl patch, due to not having the medication available. These failures affected one resident and placed all residents who require pain management at risk for further decline in their mental and/or physical functioning, unnecessary pain, and discomfort. Findings included: Review of Resident #238's electronic face sheet accessed 12/18/22 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included cancer of the esophagus (tube that connects the throat to the stomach), alcohol abuse, and heart failure. Review of Resident #238's admission MDS dated [DATE] Section C Cognitive Patterns revealed no BIMS score which indicated an assessment had not been completed yet. Review of Section J Health Conditions J0100. Pain Management revealed he had received PRN pain medications and non-medication intervention for pain in the five-day lookback period prior to the assessment. Section J Health Conditions J0400 Pain Frequency. Frequently. Review of Resident's #238's electronic care plan initiated 12/12/2022 revealed no evidence of a focus, objective, or interventions related to pain or a diagnosis of cancer. Review of Resident #238's discharge and admission paperwork from the hospital sent to the facility upon admission titled, Medication Administration Record, dated 12/09/2022 revealed: Hydrocodone Bitart/Acetaminophen 15 ml solution give 15 ml via feeding tube every 4 hours as needed for pain scale 4-6. Review of Resident #238's electronic physician orders accessed 12/18/22 revealed no evidence of a hydrocodone or fentanyl patch order. Further review revealed no evidence of an order for pain evaluation. Review of electronic physicians' orders revealed an order for Tylenol with Codeine #3 Tablet 300-30 MG (Acetaminophen-Codeine) Give 2 tablet via G-Tube every 4 hours as needed for Pain dated 12/12/2022. Review of the December 2022 MAR for Resident #238 revealed the following administrations: -Tylenol with Codeine #3 Tablet 300-30 MG 2 tablets given on 12/12/22 at 11:02 p.m. with an associated pain scale of 6. Follow up pain scale for this administration was listed as effective. - Tylenol with Codeine #3 Tablet 300-30 MG 2 tablets given on 12/13/22 at 5:14 p.m. with an associated pain scale of 8. Follow up pain scale for this administration was listed as effective - Tylenol with Codeine #3 Tablet 300-30 MG 2 tablets given on 12/13/22 at 10:52 p.m. with an associated pain scale of 8. Follow up pain scale for this administration was listed as effective - Tylenol with Codeine #3 Tablet 300-30 MG 2 tablets given on 12/14/22 at 3:30 a.m. with an associated pain scale of 5. Follow up pain scale for this administration was listed as effective - Tylenol with Codeine #3 Tablet 300-30 MG 2 tablets given on 12/14/22 at 2:32 p.m. with an associated pain scale of 8. Follow up pain scale for this administration was listed as effective - Tylenol with Codeine #3 Tablet 300-30 MG 2 tablets given on 12/15/22 at 7:05 a.m. with an associated pain scale of 10. Follow up pain scale for this administration was listed as effective - Tylenol with Codeine #3 Tablet 300-30 MG 2 tablets given on 12/15/22 at 8:55 p.m. with an associated pain scale of 2. Follow up pain scale for this administration was listed as effective - Tylenol with Codeine #3 Tablet 300-30 MG 2 tablets given on 12/16/22 at 8:46 a.m. with an associated pain scale of 6. Follow up pain scale for this administration was listed as effective - Tylenol with Codeine #3 Tablet 300-30 MG 2 tablets given on 12/16/22 at 2:26 p.m. with an associated pain scale of 6. Follow up pain scale for this administration was listed as effective - Tylenol with Codeine #3 Tablet 300-30 MG 2 tablets given on 12/16/22 at 10:59 p.m. with an associated pain scale of 5. Follow up pain scale for this administration was listed as effective - Tylenol with Codeine #3 Tablet 300-30 MG 2 tablets given on 12/17/22 at 6:56 p.m. with an associated pain scale of 4. Follow up pain scale for this administration was listed as effective - Tylenol with Codeine #3 Tablet 300-30 MG 2 tablets given on 12/17/22 at11:38 p.m. with an associated pain scale of 3. Follow up pain scale for this administration was listed as effective - Tylenol with Codeine #3 Tablet 300-30 MG 2 tablets given on 12/18/22 at 5:00 a.m. with an associated pain scale of 4. Follow up pain scale for this administration was listed as effective - Tylenol with Codeine #3 Tablet 300-30 MG 2 tablets given on 12/19/22 at 8:05 a.m. with an associated pain scale of 10. Follow up pain scale for this administration was listed as effective Review of skilled nurse's notes for Resident #238 revealed each note included a pain assessment. These pain assessments were documented as follows: -12/16/22 7:30 a.m. pain was 8.8 out of 10 -12/17/22 9:02 a.m. pain was 4.4 out of 10 -12/17/22 10:03 p.m. pain was 4.4 out of 10 -12/18/22 9:05 a.m. pain was 4.4 out of 10 -12/18/22 9:09 p.m. pain was 4.4 out of 10 -12/19/22 9:09 p.m. pain was 10 out of 10 Record review of Resident #238's electronic nurses notes accessed on 12/18/22 revealed a nurses' note written by LVN A, dated 12/15/22 at 6:02 PM, which read: Returned from MD appointment. Transport reported the Dr. called in orders to pharmacy and that copies will be faxed tomorrow. Further review or electronic nurses' notes revealed no evidence of documentation regarding new orders or waiting for medications to arrive. During observation and interview on 12/18/22 at 2:30 PM, Resident #238 was sitting up in bed. Resident #238 was very tense and fidgety in appearance. He stated he was in pain. He stated his pain level was at a 10 in his neck and throat area. He stated he went to his oncology doctor on Thursday (12/15/22) and got an order for hydrocodone and fentanyl patches and had not received the medication yet. He stated he was waiting for the nurse to come by to talk to her about his pain medication. He stated he felt he should not have to wait this long for pain control. During an interview on 12/19/22 at 09:32 AM, Resident #238 stated he was in a lot of pain. He stated he went to the doctor last Thursday (12/15/21) and received and order for Hydrocodone and pain patches. He stated the nurses told him that the medication had not arrived from the pharmacy yet. Resident #238 stated his pain was a level 10 out of 10 and Tylenol with Codeine did nothing for his pain. He stated the facility had not offered him anything except Tylenol with Codeine. During an interview on 12/19/22 at 10:00 AM, LVN B stated she was not aware of any new orders for pain medication for Resident #238, but she would investigate it. During an interview on 12/19/22 at 10:30 AM, LVN B stated she spoke with the DON and the medication ordered by the oncologist was still not available from the pharmacy. Record review of Resident #238's electronic nurses notes accessed on 12/19/22 revealed a nurses' note written by the DON, dated 12/19/22 at 11:47 AM, which read: .Spoke with pharmacy regarding residents' fentanyl and hydrocodone from oncologist. Pharmacist states drug order should be delivered by this afternoon around 4pm . During an interview on 12/20/22 at 10:00 AM, the DON stated the pharmacy did not have the medications in stock. She stated the pharmacy was supposed to receive a truck yesterday and deliver the medications. She stated she was about to go to the pharmacy and pick up the medications. DON stated Resident #238 told her his pain was controlled with the Tylenol with Codeine and he wanted to wait for his prescriptions. She stated he refused to take the hydrocodone from the emergency kit because he did not think it was the same as he was prescribed. She stated the facility can get all medications from their pharmacy within 24 hours of new orders and prescribed medications. She stated she did not try other alternatives to get his new medications because on 12/16/22 Resident #238 stated he was ok and wanted to wait for his medications from the pharmacy. She stated Resident #238's pain had been controlled. She stated it was not acceptable to let a resident hurt for 5 days. During an interview on 12/20/22 at 11:30 PM, Resident #238 stated when he was in the hospital, he received hydrocodone and it completely relieved his pain. He stated his acceptable pain level was a 2. He stated he had been in pain the whole time he had been in the facility. He stated the Tylenol with Codeine only brought his pain from a 10 to an 8. He stated he had never been offered any other medication. He stated was told that he had to wait until his medications came from the pharmacy. During an interview on 12/20/22 at 2:15 PM, LVN C stated when Resident #238 was admitted to the facility his admission orders had an order for hydrocodone, but the hospital did not send a triplicate for the medication. She stated the facility could not order the medication without the triplicate. She stated on 12/10/2022 Resident #238 asked for pain medication. She stated she called his primary care physician and he refused to order the hydrocodone because he was not the original physician that ordered that medication. She received an order for Tylenol with Codeine. She stated she did not call the oncologist or the hospital to get another order or a triplicate for the hydrocodone. During an interview on 12/20/22 at 3:00 PM, the DON stated the charge nurse was responsible for completing the admission assessment and orders. She stated admission orders were taken from the discharge and admission paperwork from the hospital sent to the facility upon admission titled, Medication Administration Record. She stated it was the DON's place to follow-up and ensure that this was done properly. She stated she called the hospital on Monday 12/13/22 to ask for a triplicate but was unable to get one. She stated she did not call the oncologist to get an order for the hydrocodone. She stated Resident #238's pain was being managed and the Tylenol with Codeine was effective. The DON did not provide a policy related physicians orders or medication availability. Review of facility policy titled Pain Management, Assessment Tool,' revised May 2016 revealed: pain is a subjective sensation of discomfort he received from multiple sensory nerve interactions generated by physical, chemical, biological, or psychological stimuli. Policy: complaints of pain will be assessed accordingly by the nurse and effectively managed through prescribed medications, and comfort measures, and all available resources of the facility. Goals: 1. resident identifies pain characteristics.2. Resident articulates factors that anticipatory pain. 3. Resident expresses a feeling of comfort and relief from pain. 4. Resident States and carries out appropriate pain interventions from pain relief. 5. Cognitively impaired residents will demonstrate actions of pain relief. Procedure: 1. assess residents' physical symptoms of pain, physical complaints, and daily activities . If resident complaints of pain the nurse will assess, implement relief measures as ordered and or care planned .7. Ask resident to help establish goals and develop plan for pain control. This gives resident sense of control. 8. Instruct resident in use of relaxation techniques.9. Add the resident to right pain on a scale of 1 to 10 with one being the least pain and 10 being the worst pain experience .10. Assist the resident in maintaining a pain management and reschedule, exercise program, and medication regimen .12. Talk with the resident about pain and assess for pain relief after interventions.13. Monitor for effectiveness of pain intervention.