Nursing Home News — Page 1152

## Inadequate Pain Management Protocols Inspectors identified concerning gaps in pain management for a resident experiencing chronic, severe pain.

According to the inspection report, the nurse's actions violated federal regulations governing the use of physical restraints in nursing facilities.

on July 25, 2024—medications that were ordered to be given at 9:00 a.m.

Resident 28, who has intact cognitive abilities and can make her own decisions, described her reaction to the incident during interviews with inspectors.

The resident, who had a prior fall history dating to May 2023, slipped and fell after standing up from a shower chair while reaching for clothes in her closet.

The policies also specifically required that preplanned emergency menus be available and stored separately with annual rotation.

The inspection revealed staff entering the isolation room without wearing required personal protective equipment, including gowns, gloves, and masks.

## Documentation and Monitoring Failures The March 2025 inspection uncovered significant gaps in how the facility tracked and responded to resident falls.

The Administrator and Director of Nursing were formally notified of two immediate jeopardy citations on June 7, 2024.

The hospital's discharge documentation clearly listed Type 2 Diabetes in the patient's medical history.

However, the facility's own daily documentation told a different story.

The inspection revealed multiple failures in the facility's abuse reporting and investigation protocols.