Failure to Provide Adequate Pain Management During Wound Care
Penalty
Summary
A resident with a Stage 4 pressure ulcer to the left buttock, who was nonverbal and dependent on staff for all activities of daily living, experienced unrelieved and uncontrolled pain during wound care and repositioning. The resident had a history of anoxic brain injury and functional quadriplegia, rendering her unable to express needs or communicate verbally. Staff observed and reported that the resident exhibited facial grimacing and moaning—recognized nonverbal indicators of pain—during pressure ulcer treatments and repositioning. Despite these clear signs of pain, the treatment nurse continued with wound care procedures without stopping to assess or address the resident's discomfort. The facility failed to ensure that pain management protocols were followed as ordered by the physician and outlined in the resident's care plan. Specifically, Tylenol 500 mg was not administered one hour prior to wound treatment as required, and wound care was not consistently performed within one hour after pain medication administration. Multiple instances were documented where the timing of pain medication and wound care did not align, resulting in the resident undergoing painful procedures without adequate pain relief. Additionally, nurses did not verify whether pain medication had been given before starting wound care, and staff did not consistently assess or document the resident's pain before, during, and after treatment. Interviews with nursing staff and review of records confirmed that the facility's pain assessment and management policy was not followed. Staff acknowledged that they recognized the resident's nonverbal cues as indicators of pain but failed to intervene appropriately, such as stopping treatment, reassessing pain, or notifying the physician. The care plan specifically stated that the resident should not experience pain or facial grimacing during care, yet these interventions were not implemented. The deficiency resulted in the resident experiencing unnecessary pain and suffering during routine wound care and repositioning.