Failure to Properly Assess and Manage Pain Following Resident Fall
Penalty
Summary
A deficiency was identified when the facility failed to properly assess and manage pain for a resident who experienced a fall with injury. The resident, who had a history of acute osteomyelitis, cerebral infarction, muscle weakness, lack of coordination, and chronic pain, suffered an unwitnessed fall and subsequently complained of pain in the left ribs, hip, and arm. Although initial assessments and x-rays did not reveal fractures or abnormal skin findings, the resident continued to report significant pain in the affected areas for several days following the incident. Despite ongoing complaints of pain, the resident's care plan was not updated or reviewed after the fall to reflect the new pain or to add interventions. Pain medications, including Tramadol and Percocet, were administered on an as-needed (PRN) basis, and pain scores were documented prior to administration. However, there was no documentation of pain scores after medication administration, and the facility did not implement scheduled pain medication to address the persistent pain. The documentation repeatedly noted the medications as "effective" without evidence of reassessment or adjustment to the pain management approach. Nursing notes indicated that the resident continued to exhibit signs of pain, such as yelling out and groaning, and required frequent repositioning and reassurance. Family members expressed concerns about the management of the resident's pain, and the resident was eventually transferred to the hospital at the family's request. Hospital evaluation revealed multiple fractures that had not been identified or addressed by the facility. The facility's actions did not align with its own pain management policy, which requires reassessment and care plan updates following changes in condition, such as after a fall.
Plan Of Correction
Element 1: Resident #901 no longer resides in the facility. Element 2: Current residents residing in the facility with pain are considered like residents. Current residents residing in the facility were assessed for pain on 4/3/25 by Director of Nursing/Designee. The Director of Nursing/Designee audited current residents with pain to ensure their pain was effectively managed on 4/3/25. Element 3: The Pain Management Policy was reviewed by the QAPI committee and deemed appropriate on 4/3/25. The Staff Development Coordinator/Designee educated licensed Nurses on the Pain Management Policy with emphasis on managing pain effectively when residents have a change in condition by 4/4/25 or prior to next scheduled shift. The DON/Designee will monitor residents to ensure that pain is being managed effectively for a change in condition during the clinical morning meeting. Physicians will be notified for Residents on PRN pain medications experiencing unresolved acute pain for effective pain management. Element 4: Director of Nursing/Designee will audit residents with pain to ensure pain management regimen is effective. Audits will be conducted weekly for 4 weeks and monthly thereafter until substantial compliance is achieved. Results of these Audits will be brought to the QAPI committee for review monthly. This audit will only be discontinued with substantial compliance and with the approval of the facility QAPI Committee. Administrator is responsible to maintain compliance. 4/4/25