Failure to Administer Pain Medication Before Wound Care
Penalty
Summary
The facility failed to ensure adequate pain management interventions for a resident with a Stage 4 pressure ulcer, leading to discomfort during wound care treatment. The resident had an order to be medicated with Tylenol 30-60 minutes before wound care, but this was not followed, as evidenced by the absence of documentation in the Electronic Medication Administration Record (EMAR) indicating that the medication was administered prior to the procedure. During the wound care observation, the resident expressed pain by moaning and yelling, yet the wound care nurse did not stop to assess the pain level or offer additional pain medication. The resident, who is cognitively intact, was admitted with a diagnosis of a Stage 4 pressure ulcer developed in the facility. The care plan included goals for the pressure ulcer to show signs of healing and remain free from infection, with interventions to administer medications as ordered and monitor for side effects and effectiveness. However, the failure to administer the prescribed pain medication before wound care was a deviation from the care plan and the facility's policy, which requires medication to be given prior to wound care to promote healing and ensure resident comfort.
Plan Of Correction
F684 Quality of Care CFR(s): 483.25 Plan for specific resident: On an in-service was provided to the medicine nurse to give medication per doctor's orders and to sign medication administration record after. To communicate to the treatment nurse after medication is given. On an in-service was given to staff (care nurse) on verifying with medication nurse if medication was administered. On verifying with the resident if medication was taken to ensure that medication was received before care treatment. On stopping care if resident complains of discomfort, access the level of notifying the doctor for adjustment of medication to manage resident's level. On an order from the doctor to increase the order of 325mg to 2 tabs given orally 30-60 min prior to care. Method to assure compliance for other residents: On in-service was provided to the nurses by the DON on following doctor's orders when administering medications and to sign medication administration record as given. On communicating between medication nurse and treatment nurses to ensure residents for care was medicated. On assessing resident's comfort or level during care. If the resident complains of discomfort or care process must stop. Access, level and notify physician for modification of management. System: On care nurse conducted an audit of the residents receiving care with orders of medication before change to ensure that orders are present that adequately manage their level during care. Monitoring: As of the quality assurance and performance improvement coordinator will use a monitoring tool to check on a weekly basis, for a period of 3 months, residents with medications prior to care treatment that they receive their medication as ordered and the medication ordered is adequate to manage resident's. This will be done to ensure 100% compliance.