PUEBLO, CO- ROCK CANYON RESPIRATORY AND REHABILITATION CENTER

Based on record review, observations, and interviews, the facility failed to manage pain in a manner consistent with professional standards of practice for two (#3 and #1) out of four sample residents reviewed for pain.

Specifically, the facility failed to:
-Complete a thorough pain assessment for Resident #3 and Resident #1 which included, recognizing the onset, presence of and characteristics of pain; and,
-Have pain parameters for as needed pain (PRN) medications for Resident #3 and Resident #1.

Resident #3, age less than 65, was admitted on [DATE]. According to the April 2023 CPO diagnoses included, cerebral palsy (congenital disorder of movement, muscle tone, or posture), seizure disorder, neuromuscular dysfunction of bladder and tracheostomy (opening in the windpipe).

The 3/13/23 minimum data set (MDS) assessment showed a brief interview for mental status could not be completed as the resident was not understood most of the time. The resident required extensive assistance of two for activities of daily living. The resident had limited range of motion bilaterally for both upper and lower extremities.

At 11:25 a.m., the resident was assisted out of bed into the hoyer (mechanical) lift sling. During the transfer, the resident was observed to open his mouth, teeth clenched, and teeth showing. Certified nurse aide (CNA) #1 and three additional unidentified nursing staff interpreted the expression as smiling.

–However, the facial expression was expressed with movement as pain.

The resident had not received the PRN pain medication, 30 minutes prior to movement as the care plan directed.

C. Pain management plan
The April 2023 CPO showed an order for the resident’s pain to be monitored every shift.

-There were no parameters to determine when to administer the Hydromorphone and Acetaminophen.

Non-pharmacological interventions for pain indicated were repositioning, dim light/quite environment, relaxation, distraction, music, massage every shift.

The April 2023 medication administration record (MAR) showed the repositioning, dim light/quiet
environment, and relaxation was used daily.
According to the March 2023 MAR showed the PRN Hydromorphone 4 mg was administered six times. The medication was administered each time by licensed practical nurse (LPN) #1.

The April 2023 MAR did not show the PRN medication had been administered.

The Acetaminophen 325 mg PRN was not administered for either March or April 2023.

Licensed practical nurse (LPN) #1 was interviewed on 4/5/23 at 6:50 p.m. The LPN said the assessment for pain was based on the resident’s facial expression, guarding and retracting (protecting/pulling back limbs). She said his mom would say his smiling meant he was in pain. She said he had an as needed medication for when he was in pain. LPN #1 said ,at the beginning of shifts, she stretched his legs out and medicated the resident (with Hydromorphone) prior to stretching them out.

Resident #1, under the age of 65, was admitted on [DATE]. According to the April 2023 computerized physician orders (CPO) diagnoses included quadriplegia (paralysis of the entire body from the neck down), muscle contractors of the right ankle and foot, left ankle and foot, right shoulder, left shoulder, right elbow, left elbow, and right wrist and brain injury.

RN #1 entered the resident’s room for medication administration and was asked how the nurses assessed non-verbal residents for pain and if Resident #1 had a scheduled or as-needed (PRN) pain medication. RN #1 stated the resident no longer had scheduled pain medication but did have PRN pain medication. RN #1 was asked if the medication was usually given before therapy sessions so the pain was managed. RN #1 stated yes and went to get something for the resident. Once the therapy session was completed, RN #1 administered PRN acetaminophen (Tylenol) since the resident was out of his PRN narcotic.

-The 3/13/23 pain assessment failed to identify the potential for pain, recognizing the onset, presence of pain and failed to assess the characteristics of pain. It failed to include the history of pain and factors precipitate or exacerbate pain.

Registered nurse (RN) #1 was interviewed a second time on 4/6/23 at 3:00 p.m. RN #1 said the PAINAD system automatically assigned a number of pain after the non-verbal signs of pain were entered into the eMAR. RN #1 said he administered Acetaminophen since the resident was out of his PRN narcotic Oxycodone. RN #1 said the eMAR did not have a prompt that would explain which medication to administer based on the score and there were no parameters indicated for the PRN pain medications.