**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to consult with the resident's physician when there was a significant change in the resident's physical and mental status that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications for 1 of 15 (Resident #19) residents reviewed for notification of change. The facility failed to ensure Resident #19's physician was notified of his increased pain following a wound debridement (removal of dead or unhealthy tissue from the wound to promote the healing process) by the Wound Care NP on 11/12/2024. This failure could place residents at risk for experiencing unnecessary pain, not receiving necessary treatments and medications, and a decreased quality of life. Findings included: Record review of a face sheet dated 11/20/2024 indicated Resident #19 was a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included pressure ulcer of sacral region, stage 4 (sore that extends below the subcutaneous fat into the deep tissues, including muscle, tendons, ligaments, and bone in the lower back, buttocks area) and pain. Record review of Resident #19's Quarterly MDS assessment dated [DATE] indicated he was understood by others and was able to understand others. The MDS assessment indicated Resident #19 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #19 was dependent for showering/bathing, toileting hygiene, and required supervision or touching assistance for personal hygiene. The MDS assessment indicated Resident #19 received pain medications as needed. The MDS assessment did not indicate Resident #19 received non-medication intervention for pain. The MDS assessment indicated Resident #19 experienced pain occasionally, it occasionally affected his sleep, and it rarely or not at all interfered with his therapy and day-to-day activities. Record review of Resident #19's care plan with a target date of 01/21/2025 indicated he had acute/chronic pain related to low backpain, gout (pain, swelling of the joints), and rhabdomyolysis (muscle injury or breakdown). Interventions included to administer allopurinol, Tylenol, oxycodone as per orders to give half an hour before treatments or care, anticipate the residents need for pain relief and respond immediately to any complaint of pain, and evaluate the effectiveness of pain interventions, review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Resident #19's care plan indicated he had a stage 4 pressure injury/ulcer to left buttock related to obesity, immobility, and refusal of care. Interventions included to administer medications as ordered, monitor/document for side effects and effectiveness, administer treatments as ordered and monitor for effectiveness, and to treat pain as per orders prior to treatment/turning to ensure the resident's comfort. Record review of Resident #19's Order Summary Report dated 11/19/2024 indicated: Oxycodone 10 mg give 1 tablet by mouth every 4 hours as needed for severe pain may use oxycodone 5 mg 2 tablets to equal 10 mg with a start date of 03/19/2024. Tylenol give 1000 mg by mouth every 8 hours as needed for pain with a start date of 03/19/2024. Hydrocodone-Acetaminophen 7.5-325 mg give 1 tablet by mouth every 6 hours as needed for pain related to pressure ulcer of sacral region, stage 4 with a start date of 09/29/2024. Wound left buttock apply lidocaine 5% to wound center prior to procedure. Cleanse wound and peri-wound (around the wound) with normal saline, apply barrier cream around wound, apply collagen with silver, finish packing with normal saline moistened Kerlix AMD (gauze dressing used to reduce the growth of bacteria), cover with gauze and abdominal pad, secure with tape, change daily every day shift with a start date of 11/12/2024. Wound left buttock apply lidocaine 5% to wound center prior to procedure. Cleanse wound and peri-wound with normal saline, apply barrier cream around wound, apply collagen with silver, finish packing with normal saline moistened Kerlix AMD, cover with gauze and abdominal pad, secure with tape, change daily every day shift with a start date of 11/13/2024. Hydrocodone-Acetaminophen 5-325 mg give 2 tablets by mouth every 24 hours as needed for pain related to pressure ulcer of sacral region, stage 4 give prior to wound care treatments with a start date of 11/19/2024. Hydrocodone-Acetaminophen 7.5-325 mg give 2 tablets by mouth every day shift related to pain give daily prior to wound care with at start date of 11/19/2024. Record review of Resident #19's Wound-Weekly Observation Tool dated 11/10/2024 indicated he had a stage 4 pressure ulcer to the left buttock which he admitted with. The measurements were length 2 cm, width 1.4 cm, depth 2.5 cm. The wound had undermining (a wound complication that occurs when the edges of the wound separate this creates a pocket of dead space beneath the skin, the damage extends underneath). The Wound-Weekly Observation tool indicated Resident #19 had pain prior to wound treatment. The rating of the resident's pain was left unanswered. Pain interventions included pain medication prior to treatment and lidocaine cream applied in the wound bed. Record review of Resident #19's Wound-Weekly Observation Tool dated 11/12/2024 indicated he had a stage 4 pressure ulcer to the left buttock which he admitted with. The measurements were length 2.9 cm, width 1.4 cm, depth 2.3 cm. The wound had undermining (a wound complication that occurs when the edges of the wound separate this creates a pocket of dead space beneath the skin, the damage extends underneath). The Wound-Weekly Observation tool indicated Resident #19 had pain prior to wound treatment. The rating of the resident's pain was left unanswered. Pain interventions included pain medication prior to treatment and lidocaine cream applied in the wound bed. Record review of Resident #19's progress notes dated 11/12/2024-11/19/2024 did not indicate Resident #19's wound was debrided by the Wound Care NP, and they did not indicate Resident #19 had increased pain. Record review of Resident #19's November 2024 MAR indicated. is this resident in pain? 0 indicated no pain, 1-3 indicated mild pain, 4-6 indicated moderate pain, 7-10 indicated severe pain. 11/12/2024: day shift, evening shift, and night shift indicated 0 (no pain). 11/13/2024: day shift and evening shift indicated 0 (no pain), night shift indicated 4 (moderate pain). 11/14/2024: day shift and evening shift indicated 0 (no pain), night shift indicated 4 (moderate pain). 11/15/2024: day shift 1 (mild pain), evening shift 4 (moderate pain), night shift 0 (no pain). 11/16/2024: day shift 4 (moderate pain), evening shift 4 (moderate pain), night shift 0 (no pain). 11/17/2024: day shift 0 (no pain), evening shift 3 (mild pain), night shift 0 (no pain). 11/18/2024: day shift 5 (moderate pain), evening shift 0 (no pain), night shift 0 (no pain). Record review of Resident #19's November 2024 MAR indicated, Norco 7.5-325 mg (Hydrocodone-Acetaminophen) give 1 tablet by mouth every 6 hours as needed for pain related to pressure ulcer of sacral region, stage 4 order date 09/29/2024: Administered 11/13/2024 for pain level of 5, 10:08 AM and was effective. Administered 11/14/2024 for pain level of 4, 8:56 AM and was effective. Administered 11/15/2024 for pain level of 4, 7:30 AM and was effective. Administered 11/15/2024 for pain level of 4, 5:47 PM and was effective. Administered 11/17/2024 for pain level of 9, 9:32 AM and was effective. Administered 11/18/2024 for pain level of 5, 9:01 AM and was effective. Record review of Resident #19's November 2024 MAR indicated; Tylenol Oral Tablet (Acetaminophen) give 1000 mg by mouth every 8 hours as needed for pain order date 03/19/2024: Administered 11/17/2024 for pain level of 8, 5:05 AM and was effective. Administered 11/18/2024 for pain level of 8, 4:59 AM and was effective. Administered 11/18/2024 for pain level of 3, 10:15 AM and was effective. Record review of Resident #19's November 2024 TAR indicated: Apply lidocaine 5% to wound center prior to procedure. Cleanse wound and peri wound with non-cytotoxic agent-normal saline, apply barrier cream around wound, apply collagen with silver, finish packing with NS moistened Kerlix AMD, cover with gauze and abdominal pad, secure with medipore tape change daily every day shift order date 10/30/2024, discontinued date 11/12/2024. The TAR indicated this was completed daily from 11/1/2024-11/11/2024. Lidocaine External Cream 5 % Apply to L buttocks topically every day shift for pain control & apply prior to wound care and leave for 2 minutes order date 06/15/2024 discontinued date 11/11/2024. The TAR indicated this was completed daily from 11/1/2024-11/10/2024. Wound #1 to left buttock apply lidocaine 5% to wound center prior to procedure. Cleanse wound and periwound with non-cytotoxic agent-normal saline, apply barrier cream around wound, apply collagen with silver, finish packing with NS moistened Kerlix AMD, cover with gauze and abdominal pad, secure with medipore tape change daily every day shift order date 11/12/2024. The TAR indicated this was completed daily from 11/13/2024-11/18/2024. During an interview on 11/18/2024 at 11:32 AM, Resident #19 said the wound care doctor had debrided his wound last week (11/12/2024), and he had been having increased pain during wound ever since. Resident #19 said the pain was while the wound care was being performed. Resident #19 said the pain did not affect his daily activities, eating, or sleep. Resident #19 said he had been asking the nurses to up his pain medication because every nerve ending is on fire. Resident #19 said they had been offloading the wound to help the pain. Resident #19 said he used to be an RN, so he was not big on narcotics (he tried not to use a lot of narcotic medications). Resident #19 said when he could he used Tylenol extra strength which usually took his pain away, but when they did the wound care, he wanted the narcotics because he did not want to hurt. Surveyor asked Resident #19 if observation of wound care could be done. Resident #19 said surveyor was going to get to listen to him holler and curse because the wound care was painful. Resident #19 said today's (11/18/2024) wound care had been completed, but surveyor could observe the wound care tomorrow (11/19/2024) since it was completed daily. Resident #19 said he could not refuse to have the wound care performed because his insurance required him to be compliant with the doctor's orders. During an observation of wound care with the Wound Care NP and LVN B on 11/19/2024 starting at 10:04 AM, Resident #19 was in bed. The Wound Care NP removed Resident #19's dressing and Resident #19 hollered out due to the pain. The Wound Care NP asked if Resident #19 wanted him to stop. Resident #19 said no to continue. The Wound Care NP continued, removed the old dressing, and measured the wound. The Wound Care NP did not apply any spray or creams to Resident #19. The Wound Care NP left, and LVN B started the wound treatment. LVN B started cleaning the wound and Resident #19 hollered out and said he had been in pain ever since the wound was debrided. LVN B asked Resident #19 if he wanted her to stop and he said no. LVN B continued and applied collagen, and Resident #19 continued to holler and said, it feels like somebody's taken a blow torch to my ass, careful please it's very sensitive. LVN B stopped and asked Resident #19, Can you take it?. Resident #19 said don't stop keep going. LVN B continued to pack the wound and Resident #19 again said feels like a torch to my butt. LVN B continued and finished the wound care. During an interview on 11/19/2024 at 10:57 AM, LVN B said Resident #19 received two hydrocodone 5-325 mg tablets prior to his wound care treatment today (11/19/2024). LVN B said Resident #19 started seeing the wound care NP last Tuesday (11/12/2024), and the wound care NP debrided Resident #19's wound on 11/12/2024. LVN B said ever since it was debrided Resident #19 had been hollering and screaming more with the wound care. LVN B said she had not contacted the doctor until yesterday afternoon (11/18/2024) and received an order for 2 hydrocodone tablets before wound care treatments. LVN B said Resident #19 was receiving oxycodone, but it was changed to hydrocodone because his insurance would not cover the oxycodone. LVN B said the order for oxycodone should have been discontinued from Resident #19's orders. LVN B said they used lidocaine prior to performing the wound care to help the pain, but when the wound care NP did his wound visits he used lidocaine spray, so she did not apply the lidocaine to Resident #19's wound prior to wound care today (11/19/2024). LVN B said she did not notice the wound care NP did not spray Resident #19 with lidocaine. LVN B said since Resident #19 had been hollering with pain she should have contacted the doctor to have his pain during wound care addressed when she noticed he had increased pain. LVN B said Resident #19 had been complaining of having a burning type of pain and said it was a burning sensation. LVN B said the lidocaine gel helped with the burning sensation, but Resident #19 was still complaining of pain. LVN B said Resident #19's pain tolerance was not very good, and he had a low pain tolerance. LVN B said pain was what the resident said it was. LVN B said she had not reported to the doctor that Resident #19 was having a burning type of pain. LVN B said Resident #19's pain was better today (11/19/2024), but he was still hurting therefore the medication was not effective. LVN B said she would contact the doctor to let him know the medication was not effective during wound care. LVN B said it was important for pain to be adequately addressed because they did not want to hurt Resident #19 and it could cause depression, a decline, and his nutrition to decline. During an attempted phone interview on 11/19/2024 at 12:29 PM, the Medical Director did not answer the phone. During an interview on 11/19/2024 at 12:31 PM, RN D said Resident #19 received pain management prior to starting his wound care. RN D said Resident #19 had a low pain tolerance, and he did complain about pain during the wound care. RN D said she put the lidocaine on the wound prior to doing his wound care and he received hydrocodone 7.5 mg prior to his wound treatment. RN D said she barely removed the tape and Resident #19 hollered with pain, and she would ask him if he wanted her to stop and Resident #19 said to proceed. RN D said the lidocaine relieved some of Resident #19's pain. RN D said Resident #19 described the pain to the wound as sore. RN D said she did not report to the doctor Resident #19 was having pain because he had pain every single time they did the wound care. RN D said the doctor was notified initially and that was why they had the order for the lidocaine and hydrocodone. RN D said Resident #19 wanted them to continue with the wound care because he knew it had to be done. RN D said she stopped and asked him if he wanted her to stop, but he had been having pain with wound care since his admission to the facility. RN D said pain was uncomfortable and it affected someone intensely. RN D said it was not good for the residents to have pain and everybody had a different type of pain. During an interview on 11/19/2024 at 1:27 PM, the Wound Care NP's wound evaluation for 11/12/2024 was requested from the DON and not received upon exit of the facility. During an interview on 11/19/2024 at 2:11 PM, the DON said pain medications should be administered 30 minutes prior to wound care. The DON said lidocaine should be applied to Resident #19's wound bed prior to wound care. The DON said in the past she had assessed Resident #19's pain and talked to him about what he wanted them to do. The DON said Resident #19 was having pain and they increased his pain medication hydrocodone 5 mg to 7.5 mg a few days ago. The DON said it was hard to judge Resident #19's pain because even if they got a wipe and just touched him and started turning him, he had the same type of expression of pain as he did during wound care. The DON said ever since the wound was debrided last week (11/12/2024) the wound had been more sensitive and sharper. The DON said the pain medication was increased to 2 tabs today (11/19/2024). The DON said prior to today the nurses had not notified her Resident #19 was having increased pain to his wound. The DON said the nurses should have called the doctor and let him know he was debrided, and the pain medication was no longer sufficient. The DON said if there was a change in condition the nurses should notify the doctor. The DON said they were not going to stop Resident #19 from hollering out. The DON said if Resident #19 was saying the pain medication was not working, they needed to make sure the medication was changed. The DON said the nurses should be assessing the pain and asking the residents if it was something new, where the location was, had the intensity changed, if it was acute or chronic pain, and ask the resident if the medication was effective. The DON said they would also try alternatives for pain relief such as a low air loss mattress, ice pack, repositioning, pain patches. The DON said she did not think their pain assessment included the type of pain the patient was experiencing such as if it was throbbing or burning or what type of pain. The DON said it was hard with someone that was bedbound to do more interventions. The DON said Resident #19 was not receiving therapy for his wound, but he was receiving physical therapy to maintain his mobility. The DON said if a resident's pain was not managed properly, it could affect their mood and their day-to-day activity. During an attempted phone interview on 11/20/2024 at 11:49 AM, the Medical Director did not answer the phone. During an interview on 11/20/2024 at 12:06 PM, the Wound Care NP said last Tuesday (11/12/2024) was the first time he had seen Resident #19, and he may have debrided Resident #19's wound but he was not sure because he usually did not debride on the first visit. The Wound Care NP said Resident #19 had yelled out due to the pain during the first visit, but they asked him if he wanted them to stop and Resident #19 replied no. The Wound Care NP said the way Resident #19 acted during the wound visit this week (11/19/2024) was the example of how he had acted the previous week. The Wound Care NP said, not that I remember he did not have any pain. The Wound Care NP said he only used lidocaine spray when he debrided wounds, therefore he did not use the lidocaine spray on Resident #19 on 11/19/2024. The Wound Care NP said when people are premedicated they do a lot better. The Wound Care NP said Resident #19 had been premedicated on the visit for 11/19/2024. The Wound Care NP said when people received pain medications prior to the wound care visit they did better and were less sensitive. The Wound Care NP said if a person was reporting pain and burning pain, they needed to address the pain with medications. The Wound Care NP said the facility should consider giving Resident #19 pain medications prior to his treatment because he was sensitive to pain. The Wound Care NP said the mental anticipation of pain was making Resident #19's pain more severe. The Wound Care NP said if the current medications being used for pain during wound care were not working, they needed to see what we need to do, increase the dose or have additional medication to help the pain. The Wound Care NP said the facility was responsible for contacting the facility's medical director to obtain orders for pain medication. During an interview on 11/20/2024 at 3:22 PM, the Administrator said if a resident was having pain, he expected the nurses to contact the doctor. The Administrator said they wanted to keep pain as low as feasibly possible. The Administrator said some residents had concerns regarding the use of medications for pain, but they should give them over the counter medications and try to abide by their wishes. The Administrator said it was important for the residents' pain to be addressed because pain affected the resident's quality of life in a dramatic fashion. The Administrator said increased pain could be a sign of something emergent and that could be the only warning sign of a condition. Record review of the facility's policy titled, Pain Management Program Policy, revised 01/2023, indicated, The facility will ensure that residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices, related to pain management .4. The facility will identify any situations or interventions where an increase in the resident's pain may be anticipated, for example, wound care, ambulation, or repositioning. Obtain orders for pharmaceutical interventions, pain medications, and or nonpharmaceutical interventions such as heat, cold, massage and relaxation etc. and/or refer to therapy for skilled therapeutic interventions . With a new onset of pain, complete a pain evaluation in the EMR. Determine an appropriate pharmacological intervention under the direction of the physician or a nonpharmacological intervention. Re-evaluate the resident after 45 min to one hour to determine if your intervention has been effective and document outcome in the EMR/Progress Notes and ensure new orders and updated care plan are completed .The ongoing evaluation of the status (presence, increase or reduction) of a resident's pain is vital, including the status of underlying causes, the response to interventions to prevent or manage pain, and the possible presence of adverse consequences of treatment .If pain has not been adequately controlled, it may be necessary to reconsider the current approaches and revise or supplement them as indicated .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure pain management was provided to residents who require such services, consistent with professional standards of practice for 1 of 3 residents (Resident #19) reviewed for pain. The facility failed to ensure Resident #19 received adequate pain management during wound care after he reported increased pain following a wound debridement (removal of dead or unhealthy tissue from the wound to promote the healing process) by the Wound Care NP on 11/12/2024. This failure could place residents at risk for experiencing unnecessary pain and a decreased quality of life. Findings included: Record review of a face sheet dated 11/20/2024 indicated Resident #19 was a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included pressure ulcer of sacral region, stage 4 (sore that extends below the subcutaneous fat into the deep tissues, including muscle, tendons, ligaments, and bone in the lower back, buttocks area) and pain. Record review of Resident #19's Quarterly MDS assessment dated [DATE] indicated he was understood by others and was able to understand others. The MDS assessment indicated Resident #19 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #19 was dependent for showering/bathing, toileting hygiene, and required supervision or touching assistance for personal hygiene. The MDS assessment indicated Resident #19 received pain medications as needed. The MDS assessment did not indicate Resident #19 received non-medication intervention for pain. The MDS assessment indicated Resident #19 experienced pain occasionally, it occasionally affected his sleep, and it rarely or not at all interfered with his therapy and day-to-day activities. Record review of Resident #19's care plan with a target date of 01/21/2025 indicated he had acute/chronic pain related to low backpain, gout (pain, swelling of the joints), and rhabdomyolysis (muscle injury or breakdown). Interventions included to administer allopurinol, Tylenol, oxycodone as per orders to give half an hour before treatments or care, anticipate the residents need for pain relief and respond immediately to any complaint of pain, and evaluate the effectiveness of pain interventions, review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Resident #19's care plan indicated he had a stage 4 pressure injury/ulcer to left buttock related to obesity, immobility, and refusal of care. Interventions included to administer medications as ordered, monitor/document for side effects and effectiveness, administer treatments as ordered and monitor for effectiveness, and to treat pain as per orders prior to treatment/turning to ensure the resident's comfort. Record review of Resident #19's Order Summary Report dated 11/19/2024 indicated: Oxycodone 10 mg give 1 tablet by mouth every 4 hours as needed for severe pain may use oxycodone 5 mg 2 tablets to equal 10 mg with a start date of 03/19/2024. Tylenol give 1000 mg by mouth every 8 hours as needed for pain with a start date of 03/19/2024. Hydrocodone-Acetaminophen 7.5-325 mg give 1 tablet by mouth every 6 hours as needed for pain related to pressure ulcer of sacral region, stage 4 with a start date of 09/29/2024. Wound left buttock apply lidocaine 5% to wound center prior to procedure. Cleanse wound and peri-wound (around the wound) with normal saline, apply barrier cream around wound, apply collagen with silver, finish packing with normal saline moistened Kerlix AMD (gauze dressing used to reduce the growth of bacteria), cover with gauze and abdominal pad, secure with tape, change daily every day shift with a start date of 11/12/2024. Wound left buttock apply lidocaine 5% to wound center prior to procedure. Cleanse wound and peri-wound with normal saline, apply barrier cream around wound, apply collagen with silver, finish packing with normal saline moistened Kerlix AMD, cover with gauze and abdominal pad, secure with tape, change daily every day shift with a start date of 11/13/2024. Hydrocodone-Acetaminophen 5-325 mg give 2 tablets by mouth every 24 hours as needed for pain related to pressure ulcer of sacral region, stage 4 give prior to wound care treatments with a start date of 11/19/2024. Hydrocodone-Acetaminophen 7.5-325 mg give 2 tablets by mouth every day shift related to pain give daily prior to wound care with at start date of 11/19/2024. Record review of Resident #19's Wound-Weekly Observation Tool dated 11/10/2024 indicated he had a stage 4 pressure ulcer to the left buttock which he admitted with. The measurements were length 2 cm, width 1.4 cm, depth 2.5 cm. The wound had undermining (a wound complication that occurs when the edges of the wound separate this creates a pocket of dead space beneath the skin, the damage extends underneath). The Wound-Weekly Observation tool indicated Resident #19 had pain prior to wound treatment. The rating of the resident's pain was left unanswered. Pain interventions included pain medication prior to treatment and lidocaine cream applied in the wound bed. Record review of Resident #19's Wound-Weekly Observation Tool dated 11/12/2024 indicated he had a stage 4 pressure ulcer to the left buttock which he admitted with. The measurements were length 2.9 cm, width 1.4 cm, depth 2.3 cm. The wound had undermining (a wound complication that occurs when the edges of the wound separate this creates a pocket of dead space beneath the skin, the damage extends underneath). The Wound-Weekly Observation tool indicated Resident #19 had pain prior to wound treatment. The rating of the resident's pain was left unanswered. Pain interventions included pain medication prior to treatment and lidocaine cream applied in the wound bed. Record review of Resident #19's progress notes dated 11/12/2024-11/19/2024 did not indicate Resident #19's wound was debrided by the Wound Care NP, and they did not indicate Resident #19 had increased pain. Record review of Resident #19's November 2024 MAR indicated. is this resident in pain? 0 indicated no pain, 1-3 indicated mild pain, 4-6 indicated moderate pain, 7-10 indicated severe pain. 11/12/2024: day shift, evening shift, and night shift indicated 0 (no pain). 11/13/2024: day shift and evening shift indicated 0 (no pain), night shift indicated 4 (moderate pain). 11/14/2024: day shift and evening shift indicated 0 (no pain), night shift indicated 4 (moderate pain). 11/15/2024: day shift 1 (mild pain), evening shift 4 (moderate pain), night shift 0 (no pain). 11/16/2024: day shift 4 (moderate pain), evening shift 4 (moderate pain), night shift 0 (no pain). 11/17/2024: day shift 0 (no pain), evening shift 3 (mild pain), night shift 0 (no pain). 11/18/2024: day shift 5 (moderate pain), evening shift 0 (no pain), night shift 0 (no pain). Record review of Resident #19's November 2024 MAR indicated, Norco 7.5-325 mg (Hydrocodone-Acetaminophen) give 1 tablet by mouth every 6 hours as needed for pain related to pressure ulcer of sacral region, stage 4 order date 09/29/2024: Administered 11/13/2024 for pain level of 5, 10:08 AM and was effective. Administered 11/14/2024 for pain level of 4, 8:56 AM and was effective. Administered 11/15/2024 for pain level of 4, 7:30 AM and was effective. Administered 11/15/2024 for pain level of 4, 5:47 PM and was effective. Administered 11/17/2024 for pain level of 9, 9:32 AM and was effective. Administered 11/18/2024 for pain level of 5, 9:01 AM and was effective. Record review of Resident #19's November 2024 MAR indicated; Tylenol Oral Tablet (Acetaminophen) give 1000 mg by mouth every 8 hours as needed for pain order date 03/19/2024: Administered 11/17/2024 for pain level of 8, 5:05 AM and was effective. Administered 11/18/2024 for pain level of 8, 4:59 AM and was effective. Administered 11/18/2024 for pain level of 3, 10:15 AM and was effective. Record review of Resident #19's November 2024 TAR indicated: Apply lidocaine 5% to wound center prior to procedure. Cleanse wound and peri wound with non-cytotoxic agent-normal saline, apply barrier cream around wound, apply collagen with silver, finish packing with NS moistened Kerlix AMD, cover with gauze and abdominal pad, secure with medipore tape change daily every day shift order date 10/30/2024, discontinued date 11/12/2024. The TAR indicated this was completed daily from 11/1/2024-11/11/2024. Lidocaine External Cream 5 % Apply to L buttocks topically every day shift for pain control & apply prior to wound care and leave for 2 minutes order date 06/15/2024 discontinued date 11/11/2024. The TAR indicated this was completed daily from 11/1/2024-11/10/2024. Wound #1 to left buttock apply lidocaine 5% to wound center prior to procedure. Cleanse wound and periwound with non-cytotoxic agent-normal saline, apply barrier cream around wound, apply collagen with silver, finish packing with NS moistened Kerlix AMD, cover with gauze and abdominal pad, secure with medipore tape change daily every day shift order date 11/12/2024. The TAR indicated this was completed daily from 11/13/2024-11/18/2024. During an interview on 11/18/2024 at 11:32 AM, Resident #19 said the wound care doctor had debrided his wound last week (11/12/2024), and he had been having increased pain during wound ever since. Resident #19 said the pain was while the wound care was being performed. Resident #19 said the pain did not affect his daily activities, eating, or sleep. Resident #19 said he had been asking the nurses to up his pain medication because every nerve ending is on fire. Resident #19 said they had been offloading the wound to help the pain. Resident #19 said he used to be an RN, so he was not big on narcotics (he tried not to use a lot of narcotic medications). Resident #19 said when he could he used Tylenol extra strength which usually took his pain away, but when they did the wound care, he wanted the narcotics because he did not want to hurt. Surveyor asked Resident #19 if observation of wound care could be done. Resident #19 said surveyor was going to get to listen to him holler and curse because the wound care was painful. Resident #19 said today's (11/18/2024) wound care had been completed, but surveyor could observe the wound care tomorrow (11/19/2024) since it was completed daily. Resident #19 said he could not refuse to have the wound care performed because his insurance required him to be compliant with the doctor's orders. During an observation of wound care with the Wound Care NP and LVN B on 11/19/2024 starting at 10:04 AM, Resident #19 was in bed. The Wound Care NP removed Resident #19's dressing and Resident #19 hollered out due to the pain. The Wound Care NP asked if Resident #19 wanted him to stop. Resident #19 said no to continue. The Wound Care NP continued, removed the old dressing, and measured the wound. The Wound Care NP did not apply any spray or creams to Resident #19. The Wound Care NP left, and LVN B started the wound treatment. LVN B started cleaning the wound and Resident #19 hollered out and said he had been in pain ever since the wound was debrided. LVN B asked Resident #19 if he wanted her to stop and he said no. LVN B continued and applied collagen, and Resident #19 continued to holler and said, it feels like somebody's taken a blow torch to my ass, careful please it's very sensitive. LVN B stopped and asked Resident #19, Can you take it?. Resident #19 said don't stop keep going. LVN B continued to pack the wound and Resident #19 again said feels like a torch to my butt. LVN B continued and finished the wound care. During an interview on 11/19/2024 at 10:57 AM, LVN B said Resident #19 received two hydrocodone 5-325 mg tablets prior to his wound care treatment today (11/19/2024). LVN B said Resident #19 started seeing the wound care NP last Tuesday (11/12/2024), and the wound care NP debrided Resident #19's wound on 11/12/2024. LVN B said ever since it was debrided Resident #19 had been hollering and screaming more with the wound care. LVN B said she had not contacted the doctor until yesterday afternoon (11/18/2024) and received an order for 2 hydrocodone tablets before wound care treatments. LVN B said Resident #19 was receiving oxycodone, but it was changed to hydrocodone because his insurance would not cover the oxycodone. LVN B said the order for oxycodone should have been discontinued from Resident #19's orders. LVN B said they used lidocaine prior to performing the wound care to help the pain, but when the wound care NP did his wound visits he used lidocaine spray, so she did not apply the lidocaine to Resident #19's wound prior to wound care today (11/19/2024). LVN B said she did not notice the wound care NP did not spray Resident #19 with lidocaine. LVN B said since Resident #19 had been hollering with pain she should have contacted the doctor to have his pain during wound care addressed when she noticed he had increased pain. LVN B said Resident #19 had been complaining of having a burning type of pain and said it was a burning sensation. LVN B said the lidocaine gel helped with the burning sensation, but Resident #19 was still complaining of pain. LVN B said Resident #19's pain tolerance was not very good, and he had a low pain tolerance. LVN B said pain was what the resident said it was. LVN B said she had not reported to the doctor that Resident #19 was having a burning type of pain. LVN B said Resident #19's pain was better today (11/19/2024), but he was still hurting therefore the medication was not effective. LVN B said she would contact the doctor to let him know the medication was not effective during wound care. LVN B said it was important for pain to be adequately addressed because they did not want to hurt Resident #19 and it could cause depression, a decline, and his nutrition to decline. During an attempted phone interview on 11/19/2024 at 12:29 PM, the Medical Director did not answer the phone. During an interview on 11/19/2024 at 12:31 PM, RN D said Resident #19 received pain management prior to starting his wound care. RN D said Resident #19 had a low pain tolerance, and he did complain about pain during the wound care. RN D said she put the lidocaine on the wound prior to doing his wound care and he received hydrocodone 7.5 mg prior to his wound treatment. RN D said she barely removed the tape and Resident #19 hollered with pain, and she would ask him if he wanted her to stop and Resident #19 said to proceed. RN D said the lidocaine relieved some of Resident #19's pain. RN D said Resident #19 described the pain to the wound as sore. RN D said she did not report to the doctor Resident #19 was having pain because he had pain every single time they did the wound care. RN D said the doctor was notified initially and that was why they had the order for the lidocaine and hydrocodone. RN D said Resident #19 wanted them to continue with the wound care because he knew it had to be done. RN D said she stopped and asked him if he wanted her to stop, but he had been having pain with wound care since his admission to the facility. RN D said pain was uncomfortable and it affected someone intensely. RN D said it was not good for the residents to have pain and everybody had a different type of pain. During an interview on 11/19/2024 at 1:27 PM, the Wound Care NP's wound evaluation for 11/12/2024 was requested from the DON and not received upon exit of the facility. During an interview on 11/19/2024 at 2:11 PM, the DON said pain medications should be administered 30 minutes prior to wound care. The DON said lidocaine should be applied to Resident #19's wound bed prior to wound care. The DON said in the past she had assessed Resident #19's pain and talked to him about what he wanted them to do. The DON said Resident #19 was having pain and they increased his pain medication hydrocodone 5 mg to 7.5 mg a few days ago. The DON said it was hard to judge Resident #19's pain because even if they got a wipe and just touched him and started turning him, he had the same type of expression of pain as he did during wound care. The DON said ever since the wound was debrided last week (11/12/2024) the wound had been more sensitive and sharper. The DON said the pain medication was increased to 2 tabs today (11/19/2024). The DON said prior to today the nurses had not notified her Resident #19 was having increased pain to his wound. The DON said the nurses should have called the doctor and let him know he was debrided, and the pain medication was no longer sufficient. The DON said if there was a change in condition the nurses should notify the doctor. The DON said they were not going to stop Resident #19 from hollering out. The DON said if Resident #19 was saying the pain medication was not working, they needed to make sure the medication was changed. The DON said the nurses should be assessing the pain and asking the residents if it was something new, where the location was, had the intensity changed, if it was acute or chronic pain, and ask the resident if the medication was effective. The DON said they would also try alternatives for pain relief such as a low air loss mattress, ice pack, repositioning, pain patches. The DON said she did not think their pain assessment included the type of pain the patient was experiencing such as if it was throbbing or burning or what type of pain. The DON said it was hard with someone that was bedbound to do more interventions. The DON said Resident #19 was not receiving therapy for his wound, but he was receiving physical therapy to maintain his mobility. The DON said if a resident's pain was not managed properly, it could affect their mood and their day-to-day activity. During an attempted phone interview on 11/20/2024 at 11:49 AM, the Medical Director did not answer the phone. During an interview on 11/20/2024 at 12:06 PM, the Wound Care NP said last Tuesday (11/12/2024) was the first time he had seen Resident #19, and he may have debrided Resident #19's wound but he was not sure because he usually did not debride on the first visit. The Wound Care NP said Resident #19 had yelled out due to the pain during the first visit, but they asked him if he wanted them to stop and Resident #19 replied no. The Wound Care NP said the way Resident #19 acted during the wound visit this week (11/19/2024) was the example of how he had acted the previous week. The Wound Care NP said, not that I remember he did not have any pain. The Wound Care NP said he only used lidocaine spray when he debrided wounds, therefore he did not use the lidocaine spray on Resident #19 on 11/19/2024. The Wound Care NP said when people are premedicated they do a lot better. The Wound Care NP said Resident #19 had been premedicated on the visit for 11/19/2024. The Wound Care NP said when people received pain medications prior to the wound care visit they did better and were less sensitive. The Wound Care NP said if a person was reporting pain and burning pain, they needed to address the pain with medications. The Wound Care NP said the facility should consider giving Resident #19 pain medications prior to his treatment because he was sensitive to pain. The Wound Care NP said the mental anticipation of pain was making Resident #19's pain more severe. The Wound Care NP said if the current medications being used for pain during wound care were not working, they needed to see what we need to do, increase the dose or have additional medication to help the pain. The Wound Care NP said the facility was responsible for contacting the facility's medical director to obtain orders for pain medication. During an interview on 11/20/2024 at 3:22 PM, the Administrator said if a resident was having pain, he expected the nurses to contact the doctor. The Administrator said they wanted to keep pain as low as feasibly possible. The Administrator said some residents had concerns regarding the use of medications for pain, but they should give them over the counter medications and try to abide by their wishes. The Administrator said it was important for the residents' pain to be addressed because pain affected the resident's quality of life in a dramatic fashion. The Administrator said increased pain could be a sign of something emergent and that could be the only warning sign of a condition. Record review of the facility's policy titled, Pain Management Program Policy, revised 01/2023, indicated, The facility will ensure that residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices, related to pain management .2. The facility will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. 3. The facility will identify the characteristics of pain such as location, intensity, frequency, pattern, and severity .4. The facility will identify any situations or interventions where an increase in the resident's pain may be anticipated, for example, wound care, ambulation, or repositioning. Obtain orders for pharmaceutical interventions, pain medications, and or nonpharmaceutical interventions such as heat, cold, massage and relaxation etc. and/or refer to therapy for skilled therapeutic interventions .For pain that is not managed through the current care plan, whether pharmaceutical or non-pharmaceutical, the resident should be assessed for new causes of the pain and/or the need for a change in frequency, dose or a new intervention. Break through pain may require the use of a PRN or additional type of pain medication .7. Resident pain should also be assessed prior to dressing changes (wound care) and properly medicated (typically 30 minutes or more before wound care) to reduce or alleviate pain appropriately. Resident may also benefit from Physical Therapy wound care modalities to reduce pain with wound care .With a new onset of pain, complete a pain evaluation in the EMR. Determine an appropriate pharmacological intervention under the direction of the physician or a nonpharmacological intervention. Re-evaluate the resident after 45 min to one hour to determine if your intervention has been effective and document outcome in the EMR/Progress Notes and ensure new orders and updated care plan are completed .The ongoing evaluation of the status (presence, increase or reduction) of a resident's pain is vital, including the status of underlying causes, the response to interventions to prevent or manage pain, and the possible presence of adverse consequences of treatment .If pain has not been adequately controlled, it may be necessary to reconsider the current approaches and revise or supplement them as indicated .