Failure to Provide Safe and Appropriate Pain Management for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident who required such services, resulting in a deficiency. The resident, an elderly male with a history of Parkinson's disease, acute kidney failure, obstructive and reflux uropathy, BPH, and recurrent UTIs, was admitted with an indwelling catheter and was at risk for pain due to his disease process. Despite care plan interventions that included monitoring for signs and symptoms of UTI, administering analgesia as ordered, and responding immediately to complaints of pain, staff did not adequately assess or intervene when the resident's foley catheter began draining blood over a period of three days. Documentation revealed that the resident experienced almost constant pain, rated 7 out of 10, and exhibited nonverbal signs of pain such as moaning, grimacing, and agitation. However, there was no documentation of a change in condition or appropriate pain interventions during this period. Multiple staff members, including CNAs and LVNs, were aware of the resident's condition, noting blood in the catheter bag, low urine output, and the resident's discomfort and pain, particularly in the abdominal area. Despite these observations, the staff did not document the change in condition or notify the physician or hospice nurse in a timely manner. The resident's pain medications, including PRN and scheduled doses, were not administered as needed, and there was a lack of documentation regarding the effectiveness of pain interventions. The hospice nurse was not informed of the presence of blood in the catheter until several days later, at which point the resident was transferred to the ER, diagnosed with sepsis, acute urinary retention, complicated UTI, and dehydration, and subsequently died in the hospital. Interviews with staff revealed a lack of adherence to facility policy regarding pain assessment, documentation, and notification protocols. Staff reported passing information about the resident's condition from shift to shift without formal documentation or escalation. The facility's policies required timely assessment and intervention for pain, especially for nonverbal residents, and mandated communication with hospice and the physician in the event of significant changes. These protocols were not followed, resulting in a failure to provide effective pain management and appropriate clinical response to the resident's deteriorating condition.