LOS ANGELES, CA - Skyline Healthcare Center on Rowena Avenue was cited for failing to provide appropriate pain management to a resident with artificial hip joint implants, resulting in continuous uncontrolled pain that interfered with the patient's mobility and quality of life.
Inadequate Pain Control Despite Clear Protocols
During an April inspection, surveyors found that nursing staff at Skyline Healthcare Center consistently failed to manage severe pain in a resident who had undergone hip replacement surgery and was experiencing pain levels of 9 out of 10 on the standard pain scale. The resident had been prescribed oxycodone every four hours as needed for severe pain, yet staff were not administering medications according to medical protocols.
The resident was observed multiple times lying in bed, moaning with facial grimacing and labored breathing. During interviews, the patient reported: "I need pain medication. It takes hours to get my pain medications. My legs and arms hurt." The resident explained that pain had persisted since admission in February 2025, and current medications were not providing relief.
Medical records showed the resident required total assistance with basic activities like bathing, dressing, and transfers due to pain-related limitations. Despite having physician orders for both acetaminophen for mild pain and oxycodone for severe pain, nursing staff were not adequately addressing the resident's documented high pain levels.
Communication Failures Between Staff and Physicians
The investigation revealed significant breakdowns in communication protocols that left the resident without proper medical intervention. Licensed Vocational Nurse 1 acknowledged that the resident's "pain was not controlled and had not been reported to the physician." The nurse also confirmed this concern had never been discussed with the facility's Interdisciplinary Team, which is responsible for coordinating resident care.
When asked why prescribed pain medication wasn't being administered more frequently, the nurse responded that "It was not due. Medication is ordered every four hours," despite the resident's obvious distress and the availability of as-needed dosing options.
A Restorative Nurse Assistant noted that the resident consistently refused to participate in required mobility exercises due to continuous pain, but admitted she "did not inform the licensed Nurse" despite charting the resident's pain-related inability to participate in therapy.
Medical Consequences of Inadequate Pain Management
Uncontrolled pain in nursing home residents can lead to serious health complications beyond immediate suffering. When pain prevents participation in physical therapy and mobility exercises, residents face increased risks of muscle atrophy, joint stiffness, and functional decline. This is particularly concerning for hip replacement patients, who require specific rehabilitation protocols to maintain surgical outcomes and prevent complications.
The resident's inability to participate in prescribed exercises due to pain could compromise the success of the hip replacement surgery and lead to permanent mobility limitations. Additionally, chronic uncontrolled pain frequently contributes to depression, social isolation, and overall decline in quality of life.
Proper pain management protocols require nursing staff to assess pain levels regularly, administer medications as prescribed, and communicate with physicians when current treatments prove inadequate. Federal regulations mandate that nursing homes provide appropriate pain management services and ensure staff notify physicians of changes in residents' conditions within 24 hours.
Director Acknowledges Management Failures
The facility's Director of Nursing acknowledged the severity of the situation during the inspection, stating that Resident 1's "pain was not well managed, and Resident 1 suffered harm due to pain experienced." The director confirmed that the licensed staff should have notified physicians about changes in the resident's condition and that uncontrolled pain could lead to both physical and psychological decline.
When contacted during the investigation, the resident's physician confirmed that facility staff had not notified him about the patient's pain status, stating: "The resident can benefit from better pain management." Following the inspection findings, the physician ordered Norco for breakthrough pain and requested a pain management consultation.
Additional Issues Identified
The inspection also revealed violations of the facility's own written policies. According to Skyline Healthcare Center's "Change in a Resident's Condition and Status" policy, nurses must notify attending physicians within 24 hours of any changes in a resident's medical condition. The facility's "Pain Management" policy requires staff to evaluate and report residents' use of pain medications and consider consultative support when pain is complex or not responding to standard interventions.
These policy violations demonstrate systemic failures in implementing established care protocols, suggesting that staff training and oversight mechanisms were inadequate to ensure proper pain management practices.
The facility was cited under federal regulation F697 for failing to provide safe, appropriate pain management for residents requiring such services. This violation was classified as causing minimal harm but with potential for actual harm, affecting few residents in the facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Skyline Healthcare Center - La from 2025-04-14 including all violations, facility responses, and corrective action plans.
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