TIFTON, GA - Federal inspectors documented serious failures in pain management and infection control protocols at Harborview Tifton nursing facility, finding that staff continued wound care procedures despite residents' verbal expressions of pain and distress.
Residents Experienced Untreated Pain During Medical Procedures
During a March 5, 2025 inspection, surveyors observed wound care treatments where two residents clearly communicated their discomfort but received no pain relief. The violations occurred despite the facility's own policy requiring comprehensive pain assessment and management based on professional standards.
In the first documented case, a resident with a stage IV pressure ulcer was observed receiving wound care while repeatedly saying "Ouch, ouch, ouch. That hurts" and "Oh, oh" while attempting to move away from the nurse's hands during the procedure. The resident continued squirming throughout the entire dressing change as staff completed the treatment without interruption.
Medical records showed this resident had an active order for Tylenol 325mg (two tablets every six hours as needed for pressure ulcer pain) dated March 4, 2025. However, medication administration records revealed no evidence that pain medication was administered despite the clear verbal indicators of discomfort.
Second Resident Faced Similar Treatment Without Relief
Inspectors observed a second resident during wound care who was moaning and grimacing in pain as staff removed dressings from wounds on the coccyx and right buttock areas. The resident began squirming and trying to move away as nurses peeled adhesive dressings from the skin.
During the procedure, the resident's face was pressed against the bed rail, causing additional discomfort. When the resident complained about this positioning, staff told her "they were just about done" rather than adjusting her position or addressing the pain. The resident's family member, present during the treatment, had to intervene by placing a hand between the rail and the resident's face.
This resident had no active pain medication orders at the time of treatment. Previous pain medications including hydrocodone, tramadol, and hydromorphone had all been discontinued months or years earlier.
Medical Standards Require Pain Assessment and Management
Wound care procedures, particularly for pressure ulcers and surgical sites, commonly cause significant discomfort. Standard medical practice requires healthcare providers to assess pain levels before beginning procedures and provide appropriate relief measures.
Pain during wound care can increase stress hormones, delay healing, and cause psychological trauma. When patients experience unmanaged pain during medical procedures, it can lead to increased anxiety about future treatments and reluctance to report other medical concerns.
The facility's own pain management policy emphasized that treatment should be "based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management." The policy specifically outlined that pain management should include recognizing the presence of pain and addressing underlying causes.
Staff Acknowledged Protocol Failures
During interviews with inspectors, nursing staff confirmed they had failed to follow proper procedures. The wound care nurse admitted she "should have stopped and asked R1 if she needed anything for pain" and confirmed she had not assessed either resident for pain before beginning treatments.
Another nurse explained that when residents experience pain during wound care, staff should stop treatment and administer pain medication, contact the nurse practitioner for orders, or obtain emergency medications from the facility's automated dispensing system.
The Director of Nursing acknowledged that "staff should have assessed the residents for pain and determined the cause of the pain."
Infection Control Violations Compound Safety Concerns
The inspection also revealed that nursing staff failed to wear required protective gowns during wound care and personal hygiene assistance for residents under enhanced barrier precautions. These protocols are designed to prevent the spread of infectious organisms, particularly important when caring for residents with open wounds or certain medical conditions.
Staff were observed providing wound care and perineal care without gowns despite clear signage indicating enhanced barrier precautions were required. When questioned, staff members admitted they "forgot," "didn't think about it," or had "no answer" for why they failed to follow protective equipment requirements.
Facility Response and Corrective Measures
The facility's administrator indicated that staff would receive retraining on proper use of personal protective equipment and maintaining clean supply carts. The nurse practitioner stated she would follow up on residents with wounds to ensure appropriate pain management protocols are implemented.
Federal regulations require nursing homes to provide appropriate pain management for residents who need such services. Facilities must ensure that residents are free from unnecessary pain and that medical procedures are conducted with proper attention to comfort and dignity.
The violations resulted in citations for failure to provide safe pain management and inadequate infection prevention and control measures. Both violations were classified as causing actual harm to residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Tifton Health and Rehabilitation Center from 2025-03-12 including all violations, facility responses, and corrective action plans.
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