Failure to Provide Timely and Comprehensive Post-Fall Assessment and Pain Management
Penalty
Summary
A resident with a complex medical history, including cancer, heart disease, chronic kidney disease, neurocognitive disorder, and a history of falls, experienced a fall in the facility. The resident reported pain in the left hip and was found sitting on the floor by staff. Nursing documentation indicated that the resident rated the pain as moderate initially, but there was no evidence of a comprehensive post-fall assessment, such as evaluation for range of motion, limb alignment, or a detailed pain assessment. The nurse on duty confirmed that she did not assess for musculoskeletal injury or conduct a complete pain assessment following the incident. Over the next several hours, the resident's pain escalated to severe and was unrelieved by Tylenol. Despite the resident's increasing pain and the absence of timely x-ray imaging, the transfer to the hospital was delayed for approximately five hours. The attending physician stated that she had ordered a hospital transfer based on facility policy for residents on anticoagulants after an unwitnessed fall, but was not aware the resident remained in the facility overnight. The resident was eventually transferred to the hospital, where an acute left hip fracture was diagnosed and surgically repaired.