Failure to Timely Address and Manage Resident's Catheter-Related Pain
Penalty
Summary
A resident with a Foley catheter reported significant pain, rating it as 7 to 8 out of 10, and was observed to have a catheter leg strap stuck to the tip of his penis with a small amount of blood present. Despite the resident's repeated complaints of pain, the only pain medication available was a scheduled dose, with no PRN (as needed) pain medication ordered for breakthrough pain. The Unit Manager acknowledged that a request for PRN pain medication had been made to the Hospice provider, but no order had been received, and there was no documentation that the physician or Hospice had been contacted regarding the new pain on the day it was first reported. The resident's pain persisted over multiple days, and staff continued to provide catheter care without reassessing the resident's pain or obtaining appropriate pain management interventions. Communication lapses were evident, as the pain was reported to a nurse who was not assigned to the resident, and the nurse responsible did not assess the pain before proceeding with care. The Hospice nurse and Director of Operations confirmed that no calls or requests for PRN pain medication were received from the facility prior to the day the deficiency was identified, and the Hospice nurse only became aware of the pain after a subsequent visit. The facility's pain management policy required staff to evaluate and report new or uncontrolled pain to the practitioner, but this was not followed in the resident's case. Documentation was lacking regarding timely notification to the physician or Hospice, and staff failed to ensure the resident's pain was addressed before continuing with catheter care. The deficiency was substantiated by interviews, observations, and record reviews showing a delay in both assessment and intervention for the resident's pain.