Failure to Assess and Manage Resident's New Onset Hip Pain
Penalty
Summary
A resident with multiple medical conditions, including a history of falls, cognitive impairment, and mobility issues, experienced a new onset of right hip pain that was first documented by the therapy director. The therapy director reported the pain and a change in the resident's ambulatory status to the interdisciplinary team and nursing staff. Despite this notification, there was a lack of timely and thorough pain assessment and documentation by nursing staff. The assistant director of nursing and the family nurse practitioner both assessed the resident and ordered an x-ray, with the nurse practitioner instructing nursing staff to administer PRN pain medication as ordered. However, there was no documentation of pain medication being administered, and the medication administration record did not reflect any pain medication given during the relevant period. Nursing staff interviews revealed inconsistent accounts regarding the administration of pain medication. One LPN stated that pain medication was given but not documented, while another nurse reported not administering any pain medication because the resident did not verbally complain of pain during their shift. There was also a failure to document pain assessments or reviews in the resident's records, despite clear changes in the resident's condition and reports of significant pain. The facility's pain management policy requires assessment and documentation of pain, including onset, location, severity, and use of a pain rating scale, but these steps were not followed in this case. The resident remained in pain for approximately 24 hours before being hospitalized, where a right femoral neck fracture was confirmed and surgical intervention was performed. The lack of timely pain assessment, documentation, and administration of PRN pain medication resulted in the resident experiencing unmanaged pain prior to hospitalization. Progress notes and interviews confirm that the facility did not adhere to its own pain management and assessment policy during this incident.