Failure to Provide Adequate Pain Management During Wound Care
Penalty
Summary
A deficiency occurred when staff failed to provide safe and appropriate pain management for a resident with a diabetic foot ulcer during a dressing change. The resident, who had profound intellectual disabilities, severe cognitive impairment, and was non-communicative, was care planned for pain management using nonverbal indicators. The care plan included administering pain medication as ordered and monitoring for signs of pain. Despite having an as-needed order for Tramadol for pain, there was no documentation that the medication was administered prior to the observed dressing change. During the dressing change, the resident exhibited multiple nonverbal signs of pain, including pulling the foot away, whimpering, grimacing, moaning, growling, and biting fingers. The Assistant Director of Nursing performing the procedure was unaware if pain medication had been given and continued the dressing change despite these clear indicators of discomfort. Facility policy and national guidelines both require assessment and management of pain, especially for nonverbal residents, and recommend coordinating wound care with pain medication administration. These protocols were not followed, resulting in unmanaged pain during the procedure.