**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review , the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #34) of 5 residents reviewed for quality of care. The facility failed to ensure Resident #34, who suffered a fall on 04/08/2024 at approximately 4:49 PM, resulting in an intertrochanteric fracture of the right hip was properly assessed, monitored, or provided effective pain management for over 15 hours until Resident #34 was transferred to the hospital at approximately 7:22 AM on 04/09/2024. An immediate Jeopardy (IJ) situation was identified on 04/24/2024 at 5:57 PM. While the IJ was removed on 04/27/2024 at 5:30 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy because of the facility's need to evaluate the effectiveness of its corrective systems. These failures could place residents at risk of not receiving necessary medical care, harm, and death. Findings included: Review of Resident #34's Face Sheet dated 04/23/2024 reflected an [AGE] year-old male admitted to the facility on [DATE] with the following diagnosis: Displaced Intertrochanteric Fracture Of Right Femur (fracture located between the greater and lesser trochanter - tubercle of the femur near its joint with the hip bone) with onset date of 04/15/2024, Parkinsonism (motor syndrome that manifests as rigidity, tremors, and bradykinesia - slowness of movement and speed), and Chronic Combined Systolic and Diastolic Congestive Heart Failure (serious condition in which the heart does not pump blood as efficiently as it should), and Chronic Kidney Disease (condition in which the kidneys are damaged and cannot filter blood as well as they should). Further review of Face Sheet reflected that Resident #34 RP, was his #1 Emergency Contact, Financial and Care POA, and care conference person. Review of Resident #34's Nursing Home Discharge MDS Assessment, dated 04/09/2024 reflected no BIMS score for Resident #34. Section C - Cognitive Patterns C0700. Short-term Memory indicated 1. Memory problem and C1000 Cognitive Skills for Daily Decision Making indicated 1. Modified independence - some difficulty in new situations only. MDS reflected that Resident #34's discharge was unplanned for entry to Short-Term General Hospital on 04/09/2024. MDS Section J - Health Conditions, B. Received PRN pain medications OR was offered and declined? 0. No MDS for Pain Assessment Interview reflected no answers. MDS Section J - Health Conditions indicated falls, C. Major injury - bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma. MDS indicates an electronic signature of the MDS Coordinator on 04/11/2024 and by the DON on 04/12/2024 verifying assessment completion. Review of Resident #34's Comprehensive Care Plan, last reviewed on 04/22/2024 reflected Problem - I am at risk of pain, which was initiated on 08/03/2023. Goal - I will experience pain at an acceptable level through next review with a target date of 12/31/2025. Interventions - Evaluate the effectiveness of pain interventions. Review for compliance, alleviating of symptoms, dosing schedules and my satisfaction with results, impact on functional ability and impact on cognition. Notify physician if interventions are unsuccessful or if current complaint is a significant change from my experience of pain. Observation and interview on 04/23/2024 at 10:10 AM, Resident #34 was observed seated in his room in a wheelchair with his RP present. Resident #34 was not interviewable, but his RP stated that he had a fractured hip that was received as result of a fall in the facility approximately three weeks prior. Resident #34's RP stated that she called to check on Resident #34 and was advised that he was at the hospital. Interview on 04/24/2024 at 9:12 AM, Resident #34's RP confirmed that she called the facility in the early afternoon hours of Resident #34's hospitalization (04/09/2024) and was told he was at the emergency room. Resident #34's RP stated that she arrived at the emergency room at approximately 2:00 PM and he told her that he fell in his room when he went to answer the phone because he failed to set the brakes on his wheelchair. Resident #34's RP stated that he told her that when he fell he was in a lot of pain and yelled for help. Resident #34's RP stated that other than her initial call to the facility she had not discussed the fall further with the facility and had been provided no additional information. Resident #34's RP was requested to go back through her phone during the time of the fail to check for missed phone calls or messages from the facility. Interview on 04/24/2024 at 10:21 AM, Resident #34's RP notified me of a missed call and voicemail left for her on 04/09/2024 at 6:58 AM. Resident #34's RP played the message which was from a male who identified himself as LVN A notifying her that Resident #34 was being send to the hospital for that right hip, there is a fracture there. Resident #34's RP was asked if she knew how long it was from the time of his fall to him being sent to the hospital and she stated she did not know but would figure immediately. Interview on 04/24/2024 at 10:43 AM, LVN B stated that she came in to work on 04/08/2024 at 10:00 PM to work her shift. LVN B stated that during her rounds she heard Resident #34 screaming and stated that at shift change she was informed that he fell but was not told about his pain. LVN B stated that she was aware that he had an X-Ray but was unaware of the results and looked them up. LVN B stated that when she looked up the X-Ray she observed that there was a fracture and attempted to call for NP H. LVN B stated that it took a while for NP H to call and when she did she told her to give Resident #34 a Tramadol and to wait for the morning NP to handle the situation. LVN B stated that she told NP H that Resident #34 was in screaming pain but she just confirmed the order for Tramadol. LVN B stated that she was not comfortable with the order but did not know what else to do. LVN B stated that NP G came into work on 04/09/2024 between 5:30 and 6:00 AM and that she was not pleased. LVN B stated that NP G told her that under no circumstances should a resident be left in pain like Resident #34 was. LVN B stated that during the morning meeting at the end of her shift she notified the DON of what took place. LVN B stated that she was reprimanded by the DON and told to use her judgement and that if she felt Resident #34 should have been transported regardless of the order she should have done so. LVN B stated that she was new and thought she need to call the Medical Director but stated that she knew she could have called the DON and did not. Interview on 04/24/2024 at 10:45 AM, LVN A stated that he responded to Resident #34's fall in the dining area on 04/08/2024, which was unwitnessed by staff. LVN A stated that Resident #34 stated that he did not lock the wheels on his wheelchair and fell. LVN A stated that Resident #34 complained that his right upper femur area hurt and was in noticeable pain. LVN A stated that he assessed Resident #34 and helped him back into his wheelchair. LVN A stated that as he did neuro checks on Resident #34 that the pain would subside but then return. LVN A stated that he called Resident #34's RP and notified her of his fall. LVN A stated that an X-Ray was ordered for Resident #34 but could not recall if he did so or someone else. LVN A stated that he left work at approximately 10:00 PM on 04/08/2024 and returned to work at approximately 6:00 AM on 04/09/2024. LVN A stated that when he arrived Resident #34 was in pain and that NP G was with Resident #34 and called for transport to the emergency room. LVN A was asked if he contacted Resident #34's RP when he was transported and he stated that he could not recall. LVN A stated that he found out later that NP H was contacted and told them to stabilize him even after being informed of the X-Ray results. LVN A stated that in his opinion they should have sent him out because it was an acute injury that they could not treat. LVN A stated that Resident #34 should have been sent to mitigate and address any pain he had. LVN A was questioned if they can call for a transport in a situation like this and he stated they do what they are supposed to do and follow the Doctor's orders. LVN A stated that when a fall occurs they are to contact the resident's RP, DON, and Medical Director. LVN A checked his incident report and stated that it indicated he did call Resident #34's RP (displayed a check box and time of 5:02 PM or 5:04 PM) but made no notations of what was discussed. Interview on 04/24/2024 at 11:24 AM, the DON stated that she was not notified of Resident #34's fall until she came in that morning and that they should have called me. The DON stated Resident #34 fell, indicated pain, and an X-Ray was ordered. The DON stated that results came back in the middle of the night and indicated Resident #34 had a fractured hip. The DON stated that the nurse attempted to contact NP H but was unable to until an additional attempt was made. The DON stated that NP H was provided with the information of Resident #34's injury and ordered a 1-time dose of Tramadol and decided to punt it to the NP in the morning. The DON stated that NP G arrived early, did an assessment, and sent Resident #34 out. The DON stated that LVN B had the right to call for an ambulance because she is the patient's advocate but did not know and yielded to the doctor's instructions. The DON stated that she always tells staff, when in doubt send them out. The DON stated that if it was her she would have sent Resident #34 out immediately after seeing the X-Ray results. The DON stated that the Medical Director was responsible for NP H. The DON was asked about not getting a call notifying her of the fall and she stated not from LVN B, but that LVN A did call and notify her initially of the fall. Interview on 04/24/2024 at 11:47 AM, the Medical Director was questioned if Resident #34 should have been sent to the hospital immediately and she stated it depends on the situation. The Medical Director stated that NP H would not have known about Resident #34's ambulation and that they do not prevent staff in the facility from calling for an ambulance because they are with the resident. The Medical Director stated that NP H's decision could have been trumped by the judgement of the nurse in the facility. The Medical Director stated that if the nurse disagreed with NP H's decision she could have called the family for requested transport or contacted her to discuss the situation. The Medical Director stated that she would have sent Resident #34 out but that she knows him and his medical history. The Medical Director stated that NP H would have known the NP G would be in the facility early and wanted to control the pain until NP G arrived and evaluated him. The Medical Director stated that calls for the NP are routed through [Hospital Provider]. The Medical Director provided documentation of NP H at approximately 3:00 AM, which she stated she does not normally do and likely did so to explain the situation. The Medical Director discussed another note from approximately 1:30 AM on 04/09/2024 where NP H contacted the facility in reference to another patient she was contacted about. The Medical Director was asked by the person from that call would not have notified NP H of Resident #34 and she stated that they might not have known because they were assigned to different residents / areas. Follow-up interview on 04/24/2024 at 11:58 AM, LVN B stated that when she first came on shift Resident #34 appeared alright but stated that he would yell out in pain when he was turned every two hours. LVN B stated that she did not give Resident #34 the Tramadol after receiving the order because she contacted Resident #34's RP and she stated not to give it. LVN B stated that Resident was on routine Tylenol for back pain, which he was given. Interview on 04/24/2024 at 1:06 PM, NP H stated that she was not sure if the facility attempted to reach her around 1:00 AM on 04/09/2024. NP H stated that she knew NP G arrives at the facility around 5:30 to 6:30 AM. NP H stated that she wanted to allow NP G to assess him and decide which would involve Resident #34's goals of care. NP H stated that a resident's care goals, whether they are under hospice care, and other issues can dictate the care they receive. NP H stated that she did speak with someone at the facility about another resident around 1:30 AM but they did not tell her anything at that time about Resident #34. NP H read her notes and stated that she told them they could treat with comfort care and that he needed to be assessed at the facility. NP H stated that it did not surprise her that the facility did not call for an ambulance for the same reasons she stated and it being a life altering moment. NP H stated that the resident and family need to be able to make an informed decision about the resident's care. Interview on 04/24/2024 at 1:40 PM, the Administrator was questioned as to why NP H did not have Resident #34 sent to the emergency room when she had been informed by his staff of his pain and the positive X-Ray indicating fracture. The Administrator stated that he did not know because he was not a physician. The Administrator stated NP H does know that NP G arrives at the facility very early in the morning. The Administrator stated that ideally he would have wanted his LVN B to push harder if Resident #34 was in that much pain. Interview on 04/24/2024 at 3:06 PM, NP G stated that she arrived at the facility a little before 6:00 AM on 04/09/2024 and assessed Resident #34. NP G stated that she found his leg to be externally rotated and his X-Ray indicated he had a fracture, so she sent him to the hospital. NP G stated that if the facility did not have orders and the Resident was in severe pain she would have expected that the resident be sent to the hospital. NP G stated that it was not appropriate to leave a resident in pain for that many hours without treatment and felt there was some leeway and that they could have called 911 if they felt it was needed. Review of Resident #34's Electronic Health Care Progress notes revealed the following documentation and that no notes for Resident #34's pain or care took place between 4/8/2024 at 20:45 (8:45 PM) and 4/9/2024 at 01:15 (1:15 AM) and then again no documentation of care or pain until 4/9/24 at 07:24 (7:24 AM) when he was transported: 4/8/2024 16:55 Neurological Note - Observations Resident complains of pain to right upper leg/right hip 4/8/2024 17:15 Neurological Note - Observations Resident awake & alert. States it doesn't hurt very much now. 4/8/2024 17:32 Nurses Note - Resident was in the dining room, yelling for help, found on floor. Resident assessed & helped back into his chair. Resident states he did not lock his wheels & fell out of his wheel chair. Resident assessed & helped back into his chair. Resident stated at that time that his right upper leg hurts. Will get X-Rays. 4/8/2024 17:34 Neurological Note - Observations Resident awake & alert. States it doesn't hurt very much now. 4/8/2024 17:45 Neurological Note - Observations Resident awake & alert. States his right upper leg hurts when he tries to move it. 4/8/2024 18:15 Neurological Note - Observations Resident awake & alert. States his right upper leg hurts when he tries to move it. 4/8/2024 18:45 Neurological Note - Observations Resident awake & alert. States his right upper leg hurts when he tries to move it 4/8/2024 19:46 Neurological Note - Observations Resident awake & alert. States his right upper leg hurts when he tries to move it. Call light within reach 4/8/2024 20:45 Neurological Note - Observations Resident awake & alert. States his right upper leg hurts when he tries to move it. Call light within reach 4/9/2024 01:15 Nurses Note - On date and time listed above, this nurse paged the on-call MD due to receiving significant findings on Xray for this resident. No call was returned. This nurse continued to observe this resident and attempted to control his pain level by administering his scheduled pain medication. The on-call MD was paged again at 0155, call was returned at 0300. MD was notified of current situation, notified of X-ray results, and also notified of resident being in severe pain. This nurse also asked if this resident could be sent to the ER due to his severe pain and the ON-Call MD stated for this resident to remain immobilized, ordered a 1-time dose of tramadol 50mg. On call MD also stated that [NP G], NP could handle the rest when she arrives to the facility. Will continue to monitor. 04/09/2024 07:24 Nurses Note - Resident sent out to hospital via stretcher @ 07:22 for fractured right hip. V/S: 165/77, T=100.7, P=98, R=20, O2=96% 4/15/2024 14:29 Nurses Note - Resident back from hospital via stretcher with wife present status post right hip fracture. Review of Resident #34's Electronic Health Care Pain Level Summary notes revealed that Resident #34's pain was only checked and charted 1 time for the time of his fall until his transport out of the facility. The following was the documentation of Resident #34's Pain Level: 4/8/2024 14:34 0 Numerical [LVN A] * Pre-Fall 4/8/2024 17:25 5 Numerical [LVA A] * Post Fall 4/9/2024 08:56 0 Numerical [LVN B] * Post Transport Interview on 04/25/2024 at 9:22 AM, Resident #34 RP was questioned about notification and timelines she was provided by the facility. Resident #34's RP stated again that she did not receive a phone call when he fell. Resident #34's RP stated that she has never received a call from the facility asking if they could give him a dose of Tramadol. Resident #34's RP stated that she has never expressed to the facility that she did not want Resident #34 to go to the hospital and added that she did not know he was sent this time until after the fact. Resident #34's RP stated that he needed to go and that she wanted everything done possible for him. Resident #34's RP stated that the hospital did perform surgery on him and inserted a titanium rod. Resident #34's RP was advised that Resident #34's fall took place on 04/08/2024 and immediately became visibly upset. Resident #34's RP stated in the form of a question, they let him lay in that bed with a broken hip. Resident #34's RP stated that she did not know what we would call that, but she calls it neglect. Resident #34's RP stated that she was very upset that they let him lay in the bed and should have called her and continued to do so until they spoke to her. Resident #34's RP stated that when he is in pain that it is the worse thing that could happen to him. Resident #34's RP stated that he was very sensitive to pain. Interview on 04/25/2024 at 10:20 AM, the Administrator was asked if he had video footage of Resident #34's fall due to it occurring in a common area. The Administrator stated that he had not looked for it to this point but would do so. Observation and interview on 04/25/2024 at 12:30 PM, the Administrator played the video of Resident #34's fall from 04/08/2024 The video footage was captured from the opposite end of the dining area which affected the clarity and did not have audio. The Administrator identified Resident #34 as he went for a seated position in his wheelchair to standing. Resident #34 lost his balance going backwards and appeared to get tangled in the wheelchair foot pedals. Resident #34 fell towards his right side taking his wheelchair down with him at approximately 4:49 PM. Resident #34 had staff come to assist him approximately 10 seconds after the fall and a nurse arrived approximately 30 seconds after his fall. LVN I was advised by the Administrator as the subject who kneeled beside Resident #34 to help but line of sight is obstructed by a table. At approximately 4:52 PM two staff lift Resident #34 off the floor by putting their arms under his shoulders and appeared to drop him in the wheelchair from a height of six inches. Resident #34 was moved to table and left by staff at approximately 4:54 PM before staff identified by the Administrator as LVN A returns with a blood pressure cuff at approximately 4:55 PM and took his vitals. Resident #34 was later seen doing something at the table, which the Administrator stated was him using his phone and indicated that he possibly called his wife. Interview on 04/25/2024 at 2:02 PM, Resident #34's RP stated that at no time after his fall did Resident #34 call her. Resident #34's RP stated that he has difficulty operating his phone and did not know if he could make a call if he did try. Interview on 04/25/2024 at 2:43 PM, LVN I stated that she arrived in the dining room to assist with Resident #34 after his fall on 04/08/2024. LVN I stated that Resident #34 was moaning in pain, and she assessed him. LVN I was question if she assessed Resident #34 for shorting of his limb or rotation of his hip before getting him off the floor she stated that she did not and was a new nurse. LVN I stated that she though it would be okay to get him off the floor and probably should not have. LVN I stated that she did not stay in the dining area but later heard Resident #34 yell out in pain when they took him to his room. LVN I stated that they got an order for X-Ray and passed on a report to the 10:00 PM to 6:00 AM shift. LVN I was asked why Resident #34 was not sent to the hospital she stated she did not know but though that it should have been handled differently and that he should have been sent. LVN I stated that she contacted Resident #34's RP but did not document the call or conversation. Interview on 04/25/2024 at 4:00 PM, NA MM stated that she heard Resident #34 call out in pain when he fell. NA MM stated that later in the day CNA U put Resident #34 in his bed and she changed him at 9:30 PM. NA MM stated that Resident #34 was in pain because he was groaning and shouting out in pain when she moved him. NA MM stated that she felt like Resident #34 was in excruciating pain the way he was calling out. Interview on 04/26/2024 at 11:04 AM, LVN A stated that he could not recall if he contacted the doctor for the X-Ray. LVN A stated that he did help to put Resident #34 to bed on 04/08/2024. Interview on 04/26/2024 at 11:15 AM, CNA U stated that he put Resident #34 in his bed on 4/8/24 between 5:20 and 5:30 PM. CNA U stated that he put Resident #34 in the bed by himself and stated that he did not know he had a fall and was just told her needed to go to bed. CNA U stated that he did not think Resident #34 was in pain but did not work with him anymore that day. Review of [X-Ray Provider] Radiology interpretation report for Resident #34, which indicated Date of Exam: 04/08/2024. SIGNIFICANT FINDINGS RIGHT Hip X-Ray Unilateral 2-3 V (including pelvis): FINDINGS: Multiple views of the right hip and pelvis show a fracture of the right hip at the intertrochanteric region. IMPRESSION: Acute fracture of the right hip at the intertrochanteric region. Electronically Signed by: [Medical Doctor] 04/09/2024 0:17:27 (12:17 PM) CDT. There was a hand recorded note on the both of the page that indicated, Noted: [LVN B] 4/9/2024 On-call paged @ 0155 am No call returned Review of [HOSPITAL] Assessment and Plan for Resident #34 with an encounter date of 04/16/2024 and printed by NP G on 04/16/2024 at 11:45 AM revealed, History [Resident #34] is a 85 y.o. male who resides at [FACILITY] and is seen today for readmission to [FACILITY] for long-term care and rehab after hospitalization at [HOSPITAL] from 04/09/2024 to 04/15/2024 for right hip fracture. Per the hospital discharge note: PREOPERATIVE DIAGNOSIS(ES): Right intertrochanteric femur fracture PROCEDURE(S)/OPERATION(S) PERFORMED: Open reduction and internal fixation of right intertrochanteric femur fracture with a cephalomedullary nail. Review of the facility's April 2024 Call Schedule for Geriatrics revealed that NP H was on-call for the facility on 4/8/2024 and NP G was on-call for the facility 4/9/2024. Review of the facility's Abuse, Neglect and Exploitation policy with a revised date of 12/5/2016 revealed, I. POLICY: Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subject to abuse by anyone, including, but not limited to: facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardians, friends or other individuals. II. OPERATIONAL DEFINITIONS: 6. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Appendix B - Indicators of Neglect - The following are possible indicators of neglect in individuals: Complaints of pain or injury are ignored. Review of facility's Fall Prevention and Tracking policy with a revised date of 7/6/2021 revealed, I. Policy: The facility will maintain a record of each occurrence to protect the resident, personnel and facility. The existence of such record is in no way an admission of fault, neglect, or wrongdoing. Neither is such a record or indication of cause or blame. III. PROCEDURE: In the event there is a resident fall the Accident/Incident process shall be initiated. Reference(s): Related Forms: FALLS PREVENTION Post Fall Assessment Here's what we need to do: Investigate the cause of the fall: What was the resident doing before he/she fell. Record circumstances, resident outcome and staff response. Notify primary care provider. Continue to evaluate and monitor resident for 72 hours after the fall, including neuro checks as indicated. Range of motion; palpation of joints included. Presence or absence of injuries. Presence or absence of pain. The Administrator was notified on 04/24/2024 at 5:57 PM that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 04/26/2024 at 11:45 AM: Tag Cited: F-684 §483.25 - Quality of Care Issue Cited: The facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered plan, and the residents' choices. 1. Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the citation and prevent any additional residents. from suffering an adverse outcome. (Completion Date: 04/24/2024 @ 10:18PM) Resident #34 was sent to the hospital on 4/9/24 and surgical intervention was done. Resident is back at the facility as of 4/15/24 and participating in therapy services. Pain is currently being managed with 1 25mg Tramadol Q6 hrs and 1 25mg PRN for breakthrough pain. Medication was reduced to 25mg from 50mg scheduled due to sedation. The DON or designee notified the facility Medical Director of the incident. Nursing supervisors/designees completed physical assessments on all residents to identify any changes in condition and notification was made to the physician of any noted changes. No need for any emergency treatment identified with completion of resident physical assessments. 2. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 04/25/24). On 4/25/24, upon receiving the notification of Immediate Jeopardy Component from the state agency, Clinical Nursing Consultant in-service the DON and Administrator on the following. The DON/Administrator completed the following in-services on 4/25/24: Stop and Watch Provider Communication Pain Management/Assessment Fall Prevention and Management Emergency Transfers The Root Cause Analysis was conducted by the Clinical Consultant, the Quality Assurance and Improvement committee and Governing Body. Additionally, fall and fall prevention. training was completed with all non-clinical and clinical staff. All licensed nurses were educated by the DON/designee on the physician on-call process, and nurses' ability to send patients to the ED (new standing order in place) as well as utilization of SBAR and more detailed documentation of assessments completed on a resident (visible signs of injury such as but not limited to swelling, dislocation, rotation, lacerations). All licensed nurses educated on how to assess a resident post-fall including not moving a resident and lying flat to check for shorter leg or external rotation to indicate a broken hip. When a change in condition is suspected, Staff will utilize STOP AND WATCH as an assessment tool and SBAR as a communication transfer tool. Licensed nursing staff will continue to monitor/assess residents for changes in condition. For any non-emergent situations, utilize SBAR and place in physicians' communications. binder. The nurse is to note on 24-hour report awaiting return call or return. communication from MD. If there is no response within 24 hours, notify supervisor. For any emergent situations, such as but not limited to a serious, unexpected and potentially dangerous situation requiring immediate action (acute chest pain, sudden change in mental status, unrelenting pain, shortness of breath, head injury, etc.) MD is to be notified by utilizing on-call procedures. If MD is unable to be notified or response is delayed, per standing orders, send resident to ER immediately with RP notification. After the plan of care has been completed, fill out SBAR and place in physicians. communication binder. Place copy of SBAR in DON/ADON box. Nurse Staff members were not permitted to work a shift until education was completed. New hires (licensed nurses and nurse aides) will be educated on change of condition and physician notification regulations, including but not limited to life threatening conditions, clinical complications, need to alter treatment, accidents resulting in injury, adverse. consequences as well as facility policy and procedure, accordingly in orientation by human resources/designee. The mobile x-ray company updated policies to include ca[TRUNCATED]

**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 of 5 residents (Residents #34) reviewed for pain management. The facility failed to ensure Resident #34 was routinely assessed, monitored, and received effective pain management after Resident #34 fell on [DATE] at approximately 4:49 PM and sustained an intertrochanteric fracture of the right hip and was not sent out to the hospital for treatment for over 15 hours until 04/09/2024 at approximately 7:22 AM. An immediate Jeopardy (IJ) situation was identified on 04/24/2024 at 5:57 PM. While the IJ was removed on 04/27/2024 at 5:30 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy because of the facility's need to evaluate the effectiveness of its corrective systems. These failures placed residents at risk of experiencing significant pain and discomfort. Findings included: Review of Resident #34's Face Sheet dated 04/23/2024 reflected an [AGE] year-old male admitted to the facility on [DATE] with the following diagnosis: Displaced Intertrochanteric Fracture Of Right Femur (fracture located between the greater and lesser trochanter - tubercle of the femur near its joint with the hip bone) with onset date of 04/15/2024, Parkinsonism (motor syndrome that manifests as rigidity, tremors, and bradykinesia - slowness of movement and speed), and Chronic Combined Systolic and Diastolic Congestive Heart Failure (serious condition in which the heart does not pump blood as efficiently as it should), and Chronic Kidney Disease (condition in which the kidneys are damaged and cannot filter blood as well as they should). Further review of Face Sheet reflected that Resident #34 RP, was his #1 Emergency Contact, Financial and Care POA, and care conference person. Review of Resident #34's Nursing Home Discharge MDS Assessment, dated 04/09/2024 reflected no BIMS score for Resident #34. Section C - Cognitive Patterns C0700. Short-term Memory indicated 1. Memory problem and C1000 Cognitive Skills for Daily Decision Making indicated 1. Modified independence - some difficulty in new situations only. MDS reflected that Resident #34's discharge was unplanned for entry to Short-Term General Hospital on 04/09/2024. MDS Section J - Health Conditions, B. Received PRN pain medications OR was offered and declined? 0. No MDS for Pain Assessment Interview reflected no answers. MDS Section J - Health Conditions indicated falls, C. Major injury - bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma. MDS indicates an electronic signature of the MDS Coordinator on 04/11/2024 and by the DON on 04/12/2024 verifying assessment completion. Review of Resident #34's Comprehensive Care Plan, last reviewed on 04/22/2024 reflected Problem - I am at risk of pain, which was initiated on 08/03/2023. Goal - I will experience pain at an acceptable level through next review with a target date of 12/31/2025. Interventions - Evaluate the effectiveness of pain interventions. Review for compliance, alleviating of symptoms, dosing schedules and my satisfaction with results, impact on functional ability and impact on cognition. Notify physician if interventions are unsuccessful or if current complaint is a significant change from my experience of pain. Observation and interview on 04/23/2024 at 10:10 AM, Resident #34 was observed seated in his room in a wheelchair with his RP present. Resident #34 was not interviewable, but his RP stated that he had a fractured hip that was received as result of a fall in the facility approximately three weeks prior. Resident #34's RP stated that she called to check on Resident #34 and was advised that he was at the hospital. Interview on 04/24/2024 at 9:12 AM, Resident #34's RP confirmed that she called the facility in the early afternoon hours of Resident #34's hospitalization (04/09/2024) and was told he was at the emergency room. Resident #34's RP stated that she arrived at the emergency room at approximately 2:00 PM and he told her that he fell in his room when he went to answer the phone because he failed to set the brakes on his wheelchair. Resident #34's RP stated that he told her that when he fell he was in a lot of pain and yelled for help. Resident #34's RP stated that other than her initial call to the facility she had not discussed the fall further with the facility and had been provided no additional information. Resident #34's RP was requested to go back through her phone during the time of the fall to check for missed phone calls or messages from the facility. Interview on 04/24/2024 at 10:21 AM, Resident #34's RP notified me of a missed call and voicemail left for her on 04/09/2024 at 6:58 AM. Resident #34's RP played the message which was from a male who identified himself as LVN A notifying her that Resident #34 was being send to the hospital for that right hip, there is a fracture there. Resident #34's RP was asked if she knew how long it was from the time of his fall to him being sent to the hospital and she stated she did not know but would figure immediately. Interview on 04/24/2024 at 10:43 AM, LVN B stated that she came in to work on 04/08/2024 at 10:00 PM to work her shift. LVN B stated that during her rounds she heard Resident #34 screaming and stated that at shift change she was informed that he fell but did not tell her about his pain. LVN B stated that she was aware that he had an X-Ray but was unaware of the results and looked them up. LVN B stated that when she looked up the X-Ray she observed that there was a fracture and attempted to call for NP H. LVN B stated that it took a while for NP H to call and when she did she told her to give Resident #34 a Tramadol and to wait for the morning NP to handle the situation. LVN B stated that she told NP H that Resident #34 was in screaming pain but she just confirmed the order for Tramadol. LVN B stated that she was not comfortable with the order but did not know what else to do. LVN B stated that NP G came into work on 04/09/2024 between 5:30 and 6:00 AM and that she was not pleased. LVN B stated that NP G told her that under no circumstances should a resident be left in pain like Resident #34 was. LVN B stated that during the morning meeting at the end of her shift she notified the DON of what took place. LVN B stated that she was reprimanded by the DON and told to use her judgement and that if she felt Resident #34 should have been transported regardless of the order she should have done so. LVN B stated that she was new and thought she need to call the Medical Director but did state that she knew she could have called the DON and did not. Interview on 04/24/2024 at 10:45 AM, LVN A stated that he responded to Resident #34's fall in the dining area on 04/08/2024, which was unwitnessed by staff. LVN A stated that Resident #34 stated that he did not lock the wheels on his wheelchair and fell. LVN A stated that Resident #34 complained that his right upper femur area hurt and was in noticeable pain. LVN A stated that he assessed Resident #34 and helped him back into his wheelchair. LVN A stated that as he did neuro checks on Resident #34 that the pain would subside but then return. LVN A stated that he called Resident #34's RP and notified her of his fall. LVN A stated that an X-Ray was ordered for Resident #34 but could not recall if he did so or someone else. LVN A stated that he left work at approximately 10:00 PM on 04/08/2024 and returned to work at approximately 6:00 AM on 04/09/2024. LVN A stated that when he arrived Resident #34 was in pain and that NP G was with Resident #34 and called for transport to the emergency room. LVN A was asked if he contacted Resident #34's RP when he was transported and he stated that he could not recall. LVN A stated that he found out later that NP H was contacted and told them to stabilize him even after being informed of the X-Ray results. LVN A stated that in his opinion they should have sent him out because it was an acute injury that they could not treat. LVN A stated that Resident #34 should have been sent to mitigate and address any pain he had. LVN A was questioned if they can call for a transport in a situation like this and he stated they do what they are supposed to do and follow the Doctor's orders. LVN A stated that when a fall occurs they are to contact the resident's RP, DON, and Medical Director. LVN A checked his incident report and stated that it indicated he did call Resident #34's RP (displayed a check box and time of 5:02 PM or 5:04 PM) but made no notations of what was discussed. Interview on 04/24/2024 at 11:24 AM, the DON stated that she was not notified of Resident #34's fall until she came in that morning and that they should have called me. The DON stated Resident #34 fell, indicated pain, and an X-Ray was ordered. The DON stated that results came back in the middle of the night and indicated Resident #34 had a fractured hip. The DON stated that the nurse attempted to contact NP H but was unable to until an additional attempt was made. The DON stated that NP H was provided with the information of Resident #34's injury and ordered a 1-time dose of Tramadol and decided to punt it to the NP in the morning. The DON stated that NP G arrived early, did an assessment, and sent Resident #34 out. The DON stated that LVN B had the right to call for an ambulance because she is the patient's advocate but did not know and yielded to the doctor's instructions. The DON stated that she always tells staff, when in doubt send them out. The DON stated that if it was her she would have sent Resident #34 out immediately after seeing the X-Ray results. The DON stated that the Medical Director is responsible for NP H. The DON was asked about not getting a call notifying her of the fall and she stated not from LVN B, but that LVN A did call and notify her initially of the fall. Interview on 04/24/2024 at 11:47 AM, the Medical Director was questioned if Resident #34 should have been sent to the hospital immediately and she stated it depends on the situation. The Medical Director stated that NP H would not have known about Resident #34's ambulation and that they do not prevent staff in the facility from calling for an ambulance because they are with the resident. The Medical Director stated that NP H's decision could have been trumped by the judgement of the nurse in the facility. The Medical Director stated that if the nurse disagreed with NP H's decision she could have called the family for requested transport or contacted her to discuss the situation. The Medical Director stated that she would have sent Resident #34 out but that she knows him and his medical history. The Medical Director stated that NP H would have known the NP G would be in the facility early and wanted to control the pain until NP G arrived and evaluated him. The Medical Director stated that calls for the NP are routed through [Hospital Provider]. The Medical Director provided documentation of NP H at approximately 3:00 AM, which she stated she does not normally do and likely did so to explain the situation. The Medical Director discussed another note from approximately 1:30 AM on 04/09/2024 where NP H contacted the facility in reference to another patient she was contacted about. The Medical Director was asked if the person from that call would have notified NP H of Resident #34 and she stated that they might not have known because they were assigned to different residents / areas. Follow-up interview on 04/24/2024 at 11:58 AM, LVN B stated that when she first came on shift Resident #34 appeared alright but stated that he would yell out in pain when he was turned every two hours. LVN B stated that she did not give Resident #34 the Tramadol after receiving the order because she contacted Resident #34's RP and she stated not to give it. LVN B stated that Resident was a routine Tylenol for back pain, which he was given. Interview on 04/24/2024 at 1:06 PM, NP H stated that she was not sure if the facility attempted to reach her around 1:00 AM on 04/09/2024. NP H stated that she knew NP G arrives at the facility around 5:30 to 6:30 AM. NP H stated that she wanted to allow NP G to assess him and decide which would involve Resident #34's goals of care. NP H stated that a resident's care goals, whether they are under hospice care, and other issues can dictate the care they receive. NP H stated that she did speak with someone at the facility about another resident around 1:30 AM but they did not tell her anything at that time about Resident #34. NP H read her notes and stated that she told them they cold treat with comfort care and that he needed to be assessed at the facility. NP H stated that it did not surprise her that the facility did not call for an ambulance for the same reasons she stated and it being a life altering moment. NP H stated that the resident and family need to be able to make an informed decision about the resident's care. Interview on 04/24/2024 at 1:40 PM, the Administrator was questioned as to why NP H did not have Resident #34 sent to the emergency room when she had been informed by his staff of his pain and the positive X-Ray indicating fracture. The Administrator stated that he did not know because he was not a physician. The Administrator stated NP H does know that NP G arrives at the facility very early in the morning. The Administrator stated that ideally he would have wanted his LVN B to push harder if Resident #34 was in that much pain. Interview on 04/24/2024 at 3:06 PM, NP G stated that she arrived at the facility a little before 6:00 AM on 04/09/2024 and assessed Resident #34. NP G stated that she found his leg to be externally rotated and his X-Ray indicated he had a fracture, so she sent him to the hospital. NP G stated that if the facility did not have orders and the Resident was in severe pain she would have expected that the resident be sent to the hospital. NP G stated that it was not appropriate to leave a resident in pain for that many hours without treatment and felt there was some leeway and that the could have called 911 if they felt it was needed. In an interview on 04/24/2024 at 3:21 PM, Resident #34 was in room in bed. He was able to acknowledge surveyor when asked if his hip was hurting he stated yes but was not able to answer further questions due to being drowsy. Review of Resident #34's Electronic Health Care Progress notes revealed the following documentation and that no notes for Resident #34's pain or care took place between 4/8/2024 at 20:45 (8:45 PM) and 4/9/2024 at 01:15 (1:15 AM) and then again no documentation of care or pain until 4/9/24 at 07:24 (7:24 AM) when he was transported: 4/8/2024 16:55 Neurological Note - Observations Resident complains of pain to right upper leg/right hip 4/8/2024 17:15 Neurological Note - Observations Resident awake & alert. States it doesn't hurt very much now. 4/8/2024 17:32 Nurses Note - Resident was in the dining room, yelling for help, found on floor. Resident assessed & helped back into his chair. Resident states he did not lock his wheels & fell out of his wheel chair. Resident assessed & helped back into his chair. Resident stated at that time that his right upper leg hurts. Will get X-Rays. 4/8/2024 17:34 Neurological Note - Observations Resident awake & alert. States it doesn't hurt very much now. 4/8/2024 17:45 Neurological Note - Observations Resident awake & alert. States his right upper leg hurts when he tries to move it. 4/8/2024 18:15 Neurological Note - Observations Resident awake & alert. States his right upper leg hurts when he tries to move it. 4/8/2024 18:45 Neurological Note - Observations Resident awake & alert. States his right upper leg hurts when he tries to move it 4/8/2024 19:46 Neurological Note - Observations Resident awake & alert. States his right upper leg hurts when he tries to move it. Call light within reach 4/8/2024 20:45 Neurological Note - Observations Resident awake & alert. States his right upper leg hurts when he tries to move it. Call light within reach 4/9/2024 01:15 Nurses Note - On date and time listed above, this nurse paged the on-call MD due to receiving significant findings on Xray for this resident. No call was returned. This nurse continued to observe this resident and attempted to control his pain level by administering his scheduled pain medication. The on-call MD was paged again at 0155, call was returned at 0300. MD was notified of current situation, notified of X-ray results, and also notified of resident being in severe pain. This nurse also asked if this resident could be sent to he ER due to his severe pain and the ON-Call MD stated for this resident to remain immobilized, ordered a 1-time dose of Tramadol 50mg. On call MD also stated that [NP G], NP could handle the rest when she arrives to the facility. Will continue to monitor. 04/09/2024 07:24 Nurses Note - Resident sent out to hospital via stretcher @ 07:22 for fractured right hip. V/S: 165/77, T=100.7, P=98, R=20, O2=96% 4/15/2024 14:29 Nurses Note - Resident back from hospital via stretcher with wife present status post right hip fracture. Review of Resident #34's Electronic Health Care Pain Level Summary notes revealed that Resident #34's pain was only checked and charted 1 time for the time of his fall until his transport out of the facility. The following was the documentation of Resident #34's Pain Level: 4/8/2024 14:34 0 Numerical [LVN A] * Pre-Fall 4/8/2024 17:25 5 Numerical [LVA A] * Post Fall 4/9/2024 08:56 0 Numerical [LVN B] * Post Transport Interview on 04/25/2024 at 9:22 AM, Resident #34 RP was questioned about notification and timelines she was provided by the facility. Resident #34's RP stated again that she did not receive a phone call when he fell. Resident #34's RP stated that she has never received a call from the facility asking if they could give him a dose of Tramadol. Resident #34's RP stated that she has never expressed to the facility that she did not want Resident #34 to go to the hospital and added that she did not know he was sent this time until after the fact. Resident #34's RP stated that he needed to go and that she wanted everything done possible for him. Resident #34's RP stated that the hospital did perform surgery on him and inserted a titanium rod. Resident #34's RP was advised that Resident #34's fall took place on 04/08/2024 and immediately became visibly upset. Resident #34's RP stated in the form of a question, they let him lay in the that bed with a broken hip. Resident #34's RP stated that she did not know what we would call that, but she calls it neglect. Resident #34's RP stated that she was very upset that they let him lay in the bed and should have called her and continued to do so until they spoke to her. Resident #34's RP stated that when he is in pain that it is the worse thing that could happen to him. Resident #34's RP stated that he was very sensitive to pain. Interview on 04/25/2024 at 10:20 AM, the Administrator was asked if he had video footage of Resident #34's fall due to it occurring in a common area. The Administrator stated that he had not looked for it to this point but would do so. Observation and interview on 04/25/2024 at 12:30 PM, the Administrator played the video of Resident #34's fall that he was able to retrieve for Surveyors . The video footage is captured from the opposite end of the dining area which affected the clarity and did not have audio. The Administrator identified Resident #34 as he went for a seated position in his wheelchair to standing. Resident #34 lost his balance going backwards and appeared to get tangled in the wheelchair foot pedals. Resident #34 fell towards his right side taking his wheelchair down with him at approximately 4:49 PM. Resident #34 had staff come to assist him approximately 10 seconds after the fall and a nurse arrived approximately 30 seconds after his fall. LVN I was identified by the Administrator as the subject who kneeled down beside Resident #34 to help but line of sight is obstructed by a table. At approximately 4:52 PM two staff lift Resident #34 off the floor by putting their arms under his shoulders and appeared to drop him in the wheelchair from a height of six inches. Resident #34 was moved to table and left by staff at approximately 4:54 PM before staff identified by the Administrator as LVN A returns with a blood pressure cuff at approximately 4:55 PM and took his vitals. Resident #34 is later seen doing something at the table, which the Administrator stated was him using his phone and indicated that he possibly called his wife. Interview on 04/25/2024 at 2:02 PM, Resident #34's RP stated that at no time after his fall did Resident #34 call her. Resident #34's RP stated that he has difficulty operating his phone and did not know if he could make a call if he did try. Interview on 04/25/2024 at 2:43 PM, LVN I stated that she arrived in the dining room to assist with Resident #34 after his fall on 04/08/2024. LVN I stated that Resident #34 was moaning in pain, and she assessed him. LVN I was question if she assessed Resident #34 for shorting of his limb or rotation of his hip before getting him off the floor she stated that she did not and was a new nurse. LVN I stated that she though it would be okay to get him off the floor and probably should not have. LVN I stated that she did not stay in the dining area but later heard Resident #34 yell out in pain when they took him to his room. LVN I stated that they got an order for X-Ray and passed on a report to the 10:00 PM to 6:00 AM shift. LVN I was asked why Resident #34 was not sent to the hospital she stated she did not know but though that it should have been handled differently and that he should have been sent. LVN I stated that she contacted Resident #34's RP but did not document the call or conversation. Interview on 04/25/2024 at 4:00 PM, NA MM stated that she heard Resident #34 call out in pain when he fell. NA MM stated that later in the day CNA U put Resident #34 in his bed and she changed him at 9:30 PM. NA MM stated that Resident #34 was in pain because he was groaning and shouting out in pain when she moved him. NA MM stated that she felt like Resident #34 was in excruciating pain the way he was calling out. Interview on 04/26/2024 at 11:04 AM, LVN A stated that he could not recall if he contacted the doctor for the X-Ray. LVN A stated that he did help to put Resident #34 to bed on the day of his fall. Interview on 04/26/2024 at 11:15 AM, CNA U stated that he put Resident #34 in his bed on 4/8/24 between 5:20 and 5:30 PM. CNA U stated that he put Resident #34 in the bed by himself and stated that he did not know he had a fall and was just told her needed to go to bed. CNA U stated that he did not think Resident #34 was in pain but did not work with him anymore that day. Review of [X-Ray Provider] Radiology interpretation report for Resident #34, which indicated Date of Exam: 04/08/2024. SIGNIFICANT FINDINGS RIGHT Hip X-Ray Unilateral 2-3 V (including pelvis): FINDINGS: Multiple views of the right hip and pelvis show a fracture of the right hip at the intertrochanteric region. IMPRESSION: Acute fracture of the right hip at the intertrochanteric region. Electronically Signed by: [Medical Doctor] 04/09/2024 0:17:27 (12:17 PM) CDT. There was a hand recorded note on the both of the page that indicated, Noted: [LVN B] 4/9/2024 On-call paged @ 0155 am No call returned Review of [HOSPITAL] Assessment and Plan for Resident #34 with an encounter date of 04/16/2024 and printed by NP G on 04/16/2024 at 11:45 AM revealed, History [Resident #34] is a 85 y.o. male who resides at [FACILITY] and is seen today for readmission to [FACILITY] for long-term care and rehab after hospitalization at [HOSPITAL] from 04/09/2024 to 04/15/2024 for right hip fracture. Per the hospital discharge note: PREOPERATIVE DIAGNOSIS(ES): Right intertrochanteric femur fracture PROCEDURE(S)/OPERATION(S) PERFORMED: Open reduction and internal fixation of right intertrochanteric femur fracture with a cephalomedullary nail. Review of the facility's April 2024 Call Schedule for Geriatrics revealed that NP H was on-call for the facility on 4/8/2024 and NP G was on-call for the facility 4/9/2024. Review of facility's undated Pain Policy provided by Administrator revealed, SKILL 15-1 Providing Pain Relief - The assessment of pain aims to find the cause of a person's pain, identify his or her perception of pain, and determine the effect of pain on the individual. Accurate and factual pain assessment is necessary for determining a patient's response, arriving at a proper nursing diagnoses, and selecting appropriate therapies. The Nursing process offers a systematic method for pain management that results in improved pain relief for most patients. This process recognizes distinct and unique differences in patient perceptions and responses to pain. The nursing process guides you in learning to know a patient and develop an individualized plan of care. ASSESSMENT 1. Assess patient's risk for pain 2. Ask patients if they are in pain. Older adults and patients from various cultures may not admit to having pain. 5. Assess physical, behavioral, and emotional signs and symptoms of pain: a. Moaning, crying, whimpering, groaning, vocalizations c. Facial expressions. Review of the facility's Abuse, Neglect and Exploitation policy with a revised date of 12/5/2016 revealed, I. POLICY: Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subject to abuse by anyone, including, but not limited to: facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardians, friends or other individuals. II. OPERATIONAL DEFINITIONS: 6. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Appendix B - Indicators of Neglect - The following are possible indicators of neglect in individuals: Complaints of pain or injury are ignored. Review of facility's Fall Prevention and Tracking policy with a revised date of 7/6/2021 revealed, I. Policy: The facility will maintain a record of each occurrence to protect the resident, personnel and facility. The existence of such record is in no way an admission of fault, neglect, or wrongdoing. Neither is such a record or indication of cause or blame. III. PROCEDURE: In the event there is a resident fall the Accident/Incident process shall be initiated. Reference(s): Related Forms: FALLS PREVENTION Post Fall Assessment Here's what we need to do: Investigate the cause of the fall: What was the resident doing before he/she fell. Record circumstances, resident outcome and staff response. Notify primary care provider. Continue to evaluate and monitor resident for 72 hours after the fall, including neuro checks as indicated. Range of motion; palpation of joints included. Presence or absence of injuries. Presence or absence of pain. The Administrator was notified on 04/24/2024 at 5:57 PM that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 04/26/2024 at 11:45 AM: Tag Cited: F-697 §483.25(k) - Pain Management Issue Cited: Failure to Adequately Assess and Treat a Resident's Pain 1. Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date: _4/24/24 @ 10:18PM_). Resident #34 was sent to the hospital on 4/9/24 and surgical intervention was done. Resident is back at the facility as of 4/15/24 and participating in therapy services. Pain is currently being managed with 1 25mg Tramadol Q6 hrs and 1 25mg PRN for breakthrough pain. Medication was reduced to 25mg from 50mg scheduled due to sedation. The DON or designee (s) completed a pain assessment on all residents to identify any unmet pain needs/change in pain. The residents' physicians were updated with the results of the pain assessment if indicated. In response to the above-mentioned pain assessment, pain medication/dosage was/was not changed for residents directly affected by the deficient practice. The IDT met to review residents currently receiving pain management. The care plans of residents directly affected by the deficient practice were updated to reflect new/revised resident specific pain management interventions. 2. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: _4/26/24_). All facility policies and procedures regarding pain/pain management were reviewed/revised. Facilities previous pain management policy referenced [NAME], [NAME], & [NAME], 8th Edition Clinical Nursing Skills & Techniques Skill 15-1, pg. 348. A new stand-alone Pain Management Policy was written to address pain management and approved by Medical Director. [NAME], [NAME], and [NAME], 8th edition, is a widely accepted /clinical Nursing Skills & Techniques guidebook. It encompasses Quality and Safety Education for Nurses, Evidence Based Practice, Patient Centered Care, Safety, and Documentation and Collaboration. In chapter 15 you will find the Pain Assessment and Basic Comfort Measures covering pages 346 to 372. Our staff were directed to focus on pages 348/349 which provided the most appropriate information related to our geriatric population. To provide a less cumbersome process for our staff to obtain guides to pain management a Pain Policy was generated. This can be placed in the hands of every nurse in our facility. The policy encompasses the information provided in the manual in a more formatted and concise manner. On 4/25/24, upon receiving the notification of Immediate Jeopardy Component from the state agency, Clinical Nursing Consultant in-service the DON and Administrator on the following. The DON/Administrator completed the following in-services on 4/25/24: Stop and Watch Provider Communication Pain Management/Assessment Fall Prevention and Management Emergency Transfers The Root Cause Analysis was conducted by the Clinical Consultant, the Quality Assurance an improvement committee and Governing Body. Additionally, fall and fall prevention training were completed with all non-clinical and clinical staff. [TRUNCATED]