Failure to Provide Timely Pain Management Prior to Wound Care
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including muscle wasting, pelvic fractures, and contractures, did not receive appropriate pain management prior to wound care treatment. The resident was dependent on staff for all activities of daily living and had documented memory problems. Despite physician orders for scheduled and as-needed pain medications, including Tramadol and Tylenol, the resident did not receive Tramadol prior to wound care as ordered, and there was no evidence of pain assessment or administration of pain medication before the procedure. The resident was observed to be in significant discomfort, reporting pain throughout her body and stating she had not received pain medication that morning. During wound care, the resident exhibited clear signs of pain, including screaming when touched and turned, leading the treatment nurse to stop the procedure. The responsible LVN admitted to not assessing the resident's pain or administering pain medication as required, citing an intention to wait until just before wound care, but ultimately failing to do so. The facility's policy required pain assessment and timely administration of analgesics, but these steps were not followed, resulting in the resident experiencing unrelieved pain during wound treatment and personal care.