Failure to Notify Physician of New Catheter-Related Pain
Penalty
Summary
A deficiency occurred when staff failed to notify the physician of a resident's new pain associated with a Foley catheter. The resident, who had diagnoses including neurogenic bladder, schizophrenia, anxiety disorder, dysphagia, and major depressive disorder, reported significant pain (rated 7-8 out of 10) and visible blood at the catheter site. Despite the resident's repeated complaints of pain and the presence of blood, there was no documentation that the physician or hospice provider was notified of the new pain on the day it was first reported. Observations and interviews revealed that the unit manager was aware of the resident's pain and had requested a PRN pain medication from hospice, but no order was received, and the pain was not addressed promptly. The resident continued to experience pain, and staff proceeded with catheter care without reassessing or addressing the pain. Communication lapses were evident, as the pain was reported to a nurse not assigned to the resident, and the assigned nurse did not assess the pain before continuing care. Further review showed that hospice staff were not informed of the new pain until days after the initial complaint, and there was no record of calls or notes from the facility to hospice regarding the pain on the day it began. The facility's pain management policy required staff to notify the practitioner if pain was not controlled, but this was not followed, resulting in the resident experiencing ongoing pain without timely intervention or notification to the appropriate medical providers.