Failure to Assess and Manage Pain During Wound Care
Penalty
Summary
The facility failed to assess, monitor, and intervene for pain management during wound care for one resident with multiple medical conditions, including type 2 diabetes, Alzheimer's disease, peripheral vascular disease, and hypertension. The resident, who was severely cognitively impaired, had wound care orders for multiple sites and was observed during a wound care procedure to be in visible pain, grimacing, stiffening, and verbally expressing discomfort. Despite these clear signs of pain, the LPN performing the wound care did not stop the procedure or address the resident's pain, and stated afterward that they had not assessed the resident for pain prior to the procedure and were unaware of any pain medication orders for the resident. Further review revealed that from the start of the wound care order through the date of the incident, there were 35 missed opportunities to assess the resident for pain during wound care. Interviews with CNAs confirmed that the resident regularly exhibited signs of pain during wound care, such as clenching teeth, moaning, tensing up, and verbalizing that the procedure was painful. The resident also reported experiencing significant pain, rating it as an 8 out of 10 during wound care. The DON acknowledged not knowing why pain medication had not been ordered for the resident.
Removal Plan
- A pain assessment was completed on Resident #27.
- Primary care physician for Resident #27 was contacted and a new order for Tramadol, an analgesic, was obtained.
- Staff will offer PRN pain medication prior to wound care.
- Care plan for Resident #27 will be updated accordingly.
- For all other residents a new pain assessment will be completed.
- All employees will be in-serviced on pain management including recognition of pain (verbal and non-verbal signs).
- If employee is unable to come in person for training they will receive training over the phone and then in person training prior to the beginning of their next shift.