The October 7 incident at Omaha Nursing and Rehabilitation Center involved treating a softball-sized stage four pressure ulcer on the resident's sacrum. The wound measured approximately three centimeters deep and required a complex vacuum-assisted closure dressing change.
When the physician assistant began cleansing the wound, the resident immediately yelled "Ow!" The PA continued, placing skin substitute material in the wound base while the assistant director of nursing held the resident on their left side.
As staff cut black foam to fit the wound and placed it in the wound bed, the resident yelled "Ow!" again, began facial grimacing, and started crying. Both shoulders moved up and down as the person sobbed.
The nursing director began rubbing the resident's back and tried conversation to distract them. But the treatment continued.
When staff applied the top layer of dressing, the resident cried again and yelled "That hurts!" while whimpering. Staff pressed on with the procedure as the resident continued crying, grimacing, and yelling "Ouch! Oww! That Hurts!"
The final step involved powering on the wound vacuum device. When suction was applied, the resident again yelled "Ow! That hurts!"
Only then did staff provide what the inspection report called "verbal encouragement." Before leaving the room, the assistant director asked if the resident felt better. The person responded "A little bit."
Neither staff member stopped the treatment to ask if it should continue or if the resident's pain needed to be addressed.
The assistant director of nursing later confirmed the procedure can be painful. She acknowledged the resident was "crying out and yelling out ouch, oww, and that hurts" throughout the treatment.
Records showed the resident had received as-needed Oxycodone at 5:17 AM and scheduled acetaminophen at 6:00 AM. The nursing director confirmed a dose of oxycodone should have been given before the wound treatment but wasn't.
When inspectors interviewed the resident later that morning, with a licensed practical nurse present, the person rated their pain during treatment as 10 out of 10. "That's why I was crying," the resident said.
Asked if they would have liked staff to stop the treatment, the resident replied: "They didn't give me a choice, they just kept going."
The assistant director of nursing offered a different perspective during a follow-up interview that afternoon. "Yes, we could have stopped and offered Resident 1 pain medication," she said, "but I feel like the response would have been the same."
The wound itself showed signs of proper healing. The wound bed was described as "beefy red" with intact surrounding tissues and no odor. Staff followed the technical aspects of the wound vacuum protocol correctly, applying the skin substitute, foam, and dressing according to medical orders.
But the human cost was evident in the resident's sustained cries and the acknowledgment that required pain medication wasn't provided beforehand.
Stage four pressure ulcers represent the most severe category of bedsores, extending through skin and tissue down to muscle and sometimes bone. The vacuum-assisted closure therapy uses negative pressure to promote healing but can cause significant discomfort during dressing changes.
The inspection found the facility failed to ensure residents received appropriate treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. The violation affected few residents but represented minimal harm or potential for actual harm.
Federal nursing home regulations require facilities to provide care that maintains residents' dignity and ensures their comfort during medical procedures. Pain management protocols typically call for pre-medicating residents before painful procedures when ordered medications are available.
The resident's final words to inspectors captured the essential failure: no choice was offered, and the treatment continued regardless of their expressed agony.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Omaha Nursing and Rehabilitation Center from 2025-10-07 including all violations, facility responses, and corrective action plans.
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