VANCEBURG, KY- VANCEBURG HILLS

Immediately tell the resident, the resident’s doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. 36898

Based on interview, record review, and review of the facility’s policy, the facility failed to notify the resident’s physician to alter treatment when the resident’s narcotic pain medication had a delay in delivery from the pharmacy for 1 of 28 sampled residents (Resident (R) 76). R76 received his last dose of his pain medication on 08/17/2024. Even though the resident was expressing verbal and nonverbal signs and symptoms of severe pain, the facility did not notify the resident’s physician nor did the facility communicate with hospices services. The resident did not receive his pain medication until 08/19/2024. The facility was out of the resident’s medication for 40 hours, and the medication was ordered to be administered every three hours as needed. This failure resulted in the resident sustaining actual harm due to experiencing severe pain that have been avoided if the physician had been notified.

(Cross reference F656 and F697 ) The findings include: Review of the facility’s policy titled, Facility Responsibilities, revised 03/26/2024, revealed .It is the policy of this facility to uphold and comply with the facility responsibilities .13. Notification of Change. a. A facility will immediately inform the resident; consult with the resident’s physician .when there is: .ii. A significant change in the residents’ physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). iii. A need to alter treatment
significantly .

Review of R76’s undated Admission Record revealed the the facility admitted the resident on 04/10/2024 with diagnoses which included alcoholic cirrhosis of liver, congestive heart failure, pain, and unilateral inguinal hernia.

Review of R76’s quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of
07/18/2024 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. Continued review of the MDS revealed the facility assessed the resident to have received scheduled and PRN (as needed) pain medications.

During an interview on 08/19/2024 at 11:50 AM, R76 stated the facility ran out of his narcotic pain medication of Dilaudid this past weekend. The resident stated he was in severe pain over the weekend and rated his highest pain level at a 10 on a scale of zero to 10 with 10 being the most severe pain.

Review of R76’s physician’s Orders, revealed an order, Dilaudid Oral Tablet 4 MG [milligram] .Give 1 tablet every 3 hours as needed for pain, dated 08/05/2024.

Review of R76’s Medication Administration Record (MAR) for August 2024 revealed on 08/17/2024 at 4:00 PM, R76 was administered his last dose of Dilaudid medication until 08/19/2024 at 8:00 AM. The MAR also revealed R76’s pain level was assessed and documented as 8 upon administration of the Dilaudid medication on 08/17/2024 at 4:00 PM.

Review of R76’s nursing Progress Note, dated 08/18/2024 at 5:24 PM, noted, Resident has not had pain medications all day today, as we continue to wait for the refill of his Dilaudid to come in. It has been reordered a few different times over the past week, but never came in. There was no documented evidence that the resident’s physician and/or another provider was notified.

During an interview on 08/21/2024 at 10:58 PM, Licensed Practical Nurse (LPN) 1 stated the facility utilized an emergency pharmacy kit (E-kit). When asked what the facility’s practice was if a resident ran out of pain medication, and the pharmacy had not delivered it prior to the next scheduled dose, LPN1 stated she would first notify the physician and see if they wanted to order a medication from the E-kit and/or follow the physician’s instructions.

During an interview on 08/21/2024 at 11:09 AM, Nurse Practitioner (NP) 1 stated R76 was receiving hospice services; however, after collaboration with hospice, the facility was responsible for ensuring a hospice resident’s medication was available at the facility to be administered as ordered. The NP stated it was her expectation nursing would have notified herself, the on-call physician service, or the Medical Director when the resident ran out of the medication, and the pharmacy had not delivered the refill of the medication. NP1 stated had she or another provider been notified, something could have been ordered from the facility’s E-kit, and the provider could have inquired with the pharmacy what was causing the delay.

During an interview on 08/21/2024 at 11:36 AM, the Unit Manager (UM) stated the nurses should have immediately notified the resident’s physician and the hospice provider. The UM stated the physician could have ordered a pain medication stocked in the facility’s E-kit for pain such as oxycodone or hydrocodone (both were narcotic pain medication used to treat pain). The UM also stated it was important the physician would have been notified to ensure R76’s pain management needs were met.

During an interview on 08/22/2024 at 5:15 PM, LPN2 stated she administered R76’s last dose of Dilaudid on 08/17/2024 at approximately 3:00 PM. When asked if she notified the physician or another provider once she administered R76’s last dose of Dilaudid, LPN2 stated she did not notify the physician or hospice services, but she should have as this was the facility’s practice. When asked if there was a reason that she did not notify the physician, the LPN stated she thought R76’s Fentanyl patch would cover his pain.

During an interview on 08/22/2024 at 5:46 PM, the Regional Nurse Consultant (RNC) stated it was her expectation the nurses would have contacted the physician when R76’s Dilaudid was not available to be administered to him. The RNC also stated had the physician been notified, the physician could have ordered a pain medication from the E-kit. She stated the hospice physician should have been notified as well. The RNC stated it was the facility’s responsibility to ensure the resident’s medication was ordered and available to be administered to R76. The RNC further stated the facility’s Medical Director collaborated with the hospice physician, and then the Medical Director wrote the prescriptions for the hospice pain medications.

During an interview on 08/22/2024 at 6:38 PM, the Medical Director stated it was her expectation the facility’s nursing staff would have notified her that R76 was out of his Dilaudid pain medication. The Medical Director stated with the resident’s diagnoses, the dose of Dilaudid the resident was ordered and frequently administered, and the significant amount he missed, he would have experienced pain and had she been notified or another provider notified, along with hospice being notified, a one-time order for a pain medication could have been given and administered to the resident.

During an interview on 08/22/2024 at 7:42 PM, the Administrator stated it was his expectation the physician would have been notified if there was an issue with getting R76’s pain medication to the facility.