Failure to Provide Appropriate Pain Management During Wound Care
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with open wounds on the right and left temporal areas. Despite physician orders and care plan interventions requiring pain assessment and management before, during, and after wound treatments, there was no documented evidence that pain levels were monitored or that pain medications were offered or administered prior to wound care on multiple occasions. Treatment Administration Records (TARs) and Medication Administration Records (MARs) were frequently left blank for required pain assessments, and staff interviews confirmed that pain management protocols were not consistently followed. The resident was observed to exhibit both verbal and non-verbal signs of pain during activities of daily living and wound care, including screaming, guarding, and refusing care due to pain. The resident had a history of squamous cell carcinoma with open wounds on the face, which were described as tender, bleeding, and interfering with daily activities. The care plan identified both acute and chronic pain, with interventions to monitor pain characteristics and non-verbal indicators every shift and as needed. Orders were in place for both non-pharmacological and pharmacological pain management, including acetaminophen and hydrocodone-acetaminophen as needed for moderate to severe pain. However, documentation and staff interviews revealed that these interventions were not consistently implemented, and the resident was not always premedicated prior to painful treatments. Additionally, the facility failed to reevaluate the resident's pain management plan and notify the attending physician when the resident refused wound care due to pain, as required by facility policy. There was no evidence that probable causes of pain episodes were monitored or documented, nor that non-verbal pain indicators were consistently assessed. Staff, including nurses and CNAs, reported the resident's sensitivity and pain during care, but these observations were not systematically recorded or communicated to the physician. The lack of proper pain assessment and management resulted in the resident experiencing unnecessary pain and negatively impacted the resident's quality of life.