Failure to Administer PRN Pain Medication Prior to Wound Care
Penalty
Summary
A resident receiving wound care experienced inadequate pain management when a nurse performed a wound dressing change without administering ordered pain medication beforehand. During an observed dressing change, the resident stated they had requested pain medication at 2:30 PM but had not received it prior to the start of the procedure. The nurse explained that she had been performing another resident’s dressing change and therefore did not provide the medication before beginning this resident’s wound care, then asked if the resident was in pain; the resident replied that they were in pain all the time. Review of the clinical record showed a physician’s order for Oxycodone 15 mg by mouth every 4 hours as needed for pain rated 5–10 on a 1–10 scale. In an interview, the DON confirmed that the pain medication should have been administered prior to the wound care. These findings were based on resident interview, staff interview, direct observation of the wound dressing change, and review of the resident’s clinical record.
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