Based on record review and staff interview, the facility did not provide the necessary care and services to maintain the highest practical well being in accordance with a comprehensive assessment and plan of care related to pain management for 1 Resident (R) (R1) of 3 residents.
On 11/02/19, R1 experienced an acute onset of head, neck and shoulder pain. Staff faxed MD (Medical Doctor)-C, but did not receive a response. Despite R1's repeated complaints of head, neck and shoulder pain with left arm, left left hand and left leg weakness, staff did not follow-up with MD-C until 11/04/19. …
Based on interviews, record review, and facility policy review, the facility failed to ensure two of seven residents (Residents (R) 48 and R158) out of a total sample of 30 received prescribed medications to manage pain. This failure resulted in harm for both residents. Findings include:1. Review of R48's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed she was admitted to the facility on [DATE] following hospitalization for left tibia and femur fractures. She had diagnoses including pain, cramp and spasm, spondylosis (degenerative arthritis of the spine), dorsalgia (back pain), anxiety, and depression. …
D · No harm, potential for more than minimal, isolatedJuly 7, 2026
Based on interview and record review, the facility did not ensure effective pain management was provided for 1 resident (R) (R1) of 6 sampled residents.R1 was not provided effective pain management from 5/19/26 through 5/22/26.Findings include:The facility's Pain Management policy, dated July 2026, indicates: The facility will evaluate and identify residents experiencing pain; evaluate their existing pain and the cause(s); determine the type and severity of the pain; and develop a care plan for pain management .3. The Pain Evaluation will be completed in the following circumstances: Resident reports inadequate pain control .4. Following the evaluation, the nurse will notify the physician/licensed practitioner of the findings and document .and implement new orders, if received .12. …
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