Failure to Assess and Manage Pain Related to Indwelling Catheter
Penalty
Summary
A deficiency occurred when staff failed to thoroughly assess and manage a resident's pain associated with an indwelling Foley catheter. The resident, who had diagnoses including obstructive and reflux uropathy and difficulty walking, was admitted with an order for acetaminophen as needed for moderate to severe pain. Despite repeated complaints of penile pain related to the catheter, there was no evidence that pain assessments were conducted or that pain medication was administered during several days when the resident reported discomfort. Physical therapy notes documented the resident's refusal to participate in therapy due to increased penile pain from the catheter, and family members also reported the resident's ongoing pain to staff. Observations revealed that the catheter was not secured properly, causing pulling and pain, and redness and white spots were noted at the insertion site. Staff interviews confirmed that the resident's pain was reported to nurses, but there was no documentation of follow-up, pain assessment, or consistent administration of pain medication. The facility's pain management policy required identification, assessment, treatment, and evaluation of pain to maintain resident comfort. However, the lack of timely assessment and intervention for the resident's pain resulted in unaddressed discomfort, refusal of therapy, and delayed recovery. The failure to secure the catheter and respond to pain complaints was directly observed and confirmed by multiple staff and family interviews.