Failure to Provide Effective Pain Management During Catheter Care
Penalty
Summary
Facility staff failed to provide effective, person-centered pain management for a resident with a genital wound and an indwelling urinary catheter. The resident, who was cognitively intact and dependent on staff for activities of daily living, consistently reported severe pain (8 out of 10) during catheter care and manipulation. Despite the resident's clear verbal and nonverbal expressions of pain, staff did not adequately assess or address pain during these procedures. Staff acknowledged the resident's discomfort but proceeded with care without implementing pain management interventions at the time of care, and did not consistently assess for pain specific to the genital area during catheter care. The resident had physician orders for pain management, including scheduled acetaminophen, as-needed tramadol, and topical lidocaine gel for the genital wound. However, the lidocaine gel, specifically ordered for pain related to the genital wound, was not administered for the majority of scheduled doses due to unavailability. Staff did not notify the nurse practitioner or physician about the lack of lidocaine gel, nor did they offer alternative pain interventions when the medication was unavailable. The nurse practitioner and director of nursing were unaware that the lidocaine gel was not being administered and that the resident continued to experience pain during catheter care. Interviews with staff revealed that they were aware of the resident's pain during catheter care but did not consistently assess or intervene for pain at the time of care. Staff relied on post-care notification to nursing staff rather than proactive pain management. The resident reported that staff did not ask about genital pain during care and that pain was only present during catheter manipulation. Documentation showed frequent reports of pain, but interventions were not adjusted or communicated to the medical team when current pain management was ineffective or unavailable.