Failure to Provide Timely Pain Management for Resident with Colostomy
Penalty
Summary
A deficiency occurred when a resident with a history of Crohn's disease, abdominal wounds, and a colostomy experienced unmanaged pain upon admission. The resident reported that it took several days to receive pain medication, during which time her pain increased, especially when her colostomy bag broke and her skin became raw. The resident described the pain as severe, particularly during colostomy care and cleaning, and expressed distress over the delay in receiving pain relief. Review of the resident's records showed that pain was documented at a level of 6 out of 10, but neither acetaminophen nor Percocet, both of which were ordered, were administered on the days the pain was recorded. There was no documentation explaining why pain medication was not provided, nor any evidence that a physician was notified about the resident's pain levels during this period. Interviews with nursing staff and the DON confirmed that pain medication should have been administered and that a pain level of 6 warranted contacting the provider, but this did not occur. Facility policy required prompt assessment and management of pain, including obtaining physician orders and administering medication as needed. Despite these guidelines, the resident's pain was not addressed in a timely manner, and the care plan interventions to observe and manage pain were not followed. The lack of documentation and failure to provide ordered pain medication led to unmanaged pain for the resident.