Aviata At North Florida

F 0697

Provide safe, appropriate pain management for a resident who requires such services.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure that adequate pain management was provided for 2 residents (Resident #2, #9) of 3 residents that were prescribed opioid pain medications.Findings include:1.Review of Residents #2's admission record documented the resident was admitted on [DATE REDACTED] with the diagnoses including, encounter for orthopedic aftercare following surgical amputation, acquired absence of left leg above knee, acquired absence of right leg above knee, Parkinson's disease with dyskinesia, type 2 diabetes mellitus with diabetic polyneuropathy, atrial fibrillation, muscle weakness, chronic pulmonary disease, hyperlipidemia, and hypertension. During an interview on 8/25/2025 at 9:20 AM, Resident#2 stated he was supposed to get a scheduled medication every 4 hours, and he was not getting it because they don't wake him up for it. During an interview on 8/29/2025 at 7:20 AM Resident #2 stated he did not receive his medication last night at midnight (oxycodone); he stated it is always the same nurse. Review of Resident #2's physician's order dated 8/10/2025 reads, oxycodone HCL (Hydrochloride) oral tablet 5 mg (milligrams) give 1 tablet by mouth every 4 hours for pain hold if lethargic. Review of Resident #2's medication administration record (MAR) for August 2025 for administration of oxycodone HCL oral tablet 5 mg give 1 tablet by mouth every 4 hours for pain hold if lethargic, documented the medication was not administered at 12:00 AM on 8/13/2025, 8/15/2025, 8/20/2025, 8/22/2025, 8/24/2025, 8/29/2025 and at 4:00 AM on 8/17/2025. Review of Resident #2's care plan dated 3/30/2025 and revised on 4/27/2025 read, Focus: the resident has acute/chronic pain related to generalized pain, neuropathy, restless leg syndrome. Interventions: Administer analgesia (medication) as per orders. 2. Review of Residents #9's admission record documented the resident was admitted on [DATE REDACTED] with diagnoses including paraplegia, colostomy, chronic pain, major depressive disorder, benign prostatic hyperplasia and tachycardia. Review of Resident #9's physician's order dated 8/20/2025 reads, oxycodone HCL - Acetaminophen Oral tablet 5-325 mg give 1 tablet by mouth every 4 hours for non-acute pain 7-10. Review of Resident #9's MAR for August 2025 for administration of oxycodone HCL - Acetaminophen Oral tablet 5-325 mg give 1 tablet by mouth every 4 hours for non-acute pain 7-10 documented the medication was not administered at 12:00 AM on 8/22/2025, 8/24/2025, and 8/29/2025. Review of Resident #9's care plan dated 8/21/2024 and revised on 8/21/2024 read, Focus: the resident is on pain medication therapy with interventions that included administer analgesic medication as ordered by physician . During an interview on 8/29/2025 at 11:00 AM, Resident #9 stated he did not receive his scheduled pain medication last night at midnight. Resident #9 stated that he told other nurses about it but nothing was done. During an interview on 8/29/2025 at 11:45 AM, the Assistant Director of Nursing (ADON) stated that Staff B, Licensed Practical Nurse (LPN) stated Resident #2 and Resident #9 were sleeping, so she did not wake them. ADON stated Staff B, LPN did not follow the physician's orders. During an interview on 8/29/2025 at 3:24 PM, Staff B, LPN, stated both residents (Resident #2 and Resident #9) were asleep, and she did not administer the pain medication.

Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

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(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

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If continuation sheet

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