Failure to Provide Pain Management During Wound Care
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with multiple severe wounds, resulting in a deficiency identified by surveyors. The resident, a female with a history of cerebral infarction, sepsis, end-stage renal disease requiring dialysis, and multiple stage four pressure ulcers and arterial wounds, was admitted with significant medical complexity and was nonverbal with severe cognitive impairment. Despite her extensive wounds and high risk for pain, there was no care plan for pain, and her pain was not assessed or managed according to professional standards or her needs. Observations revealed that during wound care procedures, the resident exhibited clear signs of pain, such as wincing, deep breathing, and tears, particularly when bandages were removed and wounds were treated. Staff failed to assess her pain prior to wound care, did not provide timely or appropriate pain medication, and did not stop procedures to reassess or address her pain when she showed distress. Documentation showed that although there were orders for acetaminophen, these were not administered, and staff were unclear about pain assessment tools and procedures. Interviews with nursing staff indicated confusion about responsibilities for pain management, lack of documentation, and a failure to communicate or follow up on the resident's pain needs. The attending physician and wound care doctor were not notified of the resident's pain, and no additional pain management interventions were implemented until after the surveyor's intervention. The facility's own policy required assessment and management of pain, including for nonverbal residents using the PAINAD tool, but this was not followed. The deficiency was identified as Immediate Jeopardy due to the failure to provide pain management consistent with professional standards, the resident's care plan, and her goals and preferences, resulting in unmanaged pain during daily wound care treatments.
Removal Plan
- The treatment where the resident was experiencing pain was stopped until adequate pain relief could be achieved.
- Primary care provider was contacted by the director of nurses and Tylenol order changed to Extra Strength 650 mg every 8 hours scheduled and an additional dose prior to wound care.
- 100% review of residents receiving wound care for PRN pain medication orders that may be given prior to wound care was completed by Regional Compliance nurse/DON/Designee.
- Residents identified requiring wound care received new orders/order clarifications to ensure adequate pain management prior to wound care from audit completed.
- Resident identified in the audit has an allergy to acetaminophen.
- Care plans for facility residents with wounds were updated by Regional Compliance Nurse and DON with interventions to monitor, assess, and report pain during care, including wound care, and what to do if pain management is not effective.
- Regional Compliance Nurse provided in-service to DON/ADON regarding pain management during care and procedures following facility's policy for enforcement, requiring no change in company policy as the policy was effective but not being followed.
- Communication with medical provider for any resident that is experiencing uncontrolled pain during care and/or procedures using the SBAR as communication tool.
- DON/ADON will in-service nurses (LVN/RNs) by phone and/or in person regarding pain management during care and procedures and reporting uncontrolled pain to the provider using the SBAR as a communication tool.
- All nurses (LVN/RNs), including PRN nurses, who are not in serviced will not be allowed to provide resident care until training has been completed.
- The Medical Director was notified by the Administrator regarding the immediate jeopardy citation.
- An Ad-hoc QAPI meeting was held by the interdisciplinary team to discuss the immediate jeopardies and review the plan of removal.
- DON/Designee will observe wound care to ensure any residents that is receiving wound care receive effective pain management during the procedure.
- DON/Designee will review order listing report in point click care (facility electronic medical record) to see any new wound care orders and ensure that pain management orders are in place.