Failure to Address and Manage Resident Pain Related to Indwelling Catheter
Penalty
Summary
The facility failed to provide necessary care and services to relieve pain for a resident with obstructive and reflux uropathy and an indwelling catheter. The resident was admitted with diagnoses including obstructive and reflux uropathy and difficulty walking, and was assessed as able to understand and communicate needs. Orders were in place for acetaminophen as needed for moderate to severe pain, but there was no order to monitor pain levels. The resident's medication administration record showed that pain medication was not administered on several days when the resident reported pain. Multiple observations and interviews revealed that the resident experienced significant penile pain related to the Foley catheter, which was not properly secured, causing pulling and discomfort. The resident reported pain to CNAs and LVNs over several days, but no action was taken to address the pain or administer pain medication. Family members also observed the resident's discomfort and reported that the pain was affecting the resident's ability to participate in physical therapy and daily activities. Staff interviews confirmed that the pain was reported but not addressed, and the resident's pain was only acknowledged and treated after several days of complaints. Physical therapy notes indicated the resident declined therapy sessions due to pain, and staff confirmed that the pain and refusal to participate were reported to nursing staff. The DON acknowledged that the resident's pain was not addressed as required, and the MAR confirmed a lack of pain medication administration during the period of reported pain. The facility's policy required care that promotes resident well-being and dignity, but this was not followed in the resident's case.