Failure to Provide Effective Pain Management Following Resident Injury
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with multiple medical conditions, including generalized weakness, polyarthralgia, lymphedema, obesity, gout, physical debility, osteoarthritis, hypertension, and diabetes. After a fall from a sit-to-stand lift, the resident experienced increased pain and swelling in her left hand and knee, which significantly limited her ability to perform daily activities such as getting out of bed, propelling her wheelchair, and participating in social and religious activities. Observations confirmed visible swelling and limited mobility in the resident's left hand and knee, and the resident reported ongoing pain that interfered with her independence and comfort. Nursing notes did not document the fall incident but indicated that the resident began complaining of excessive pain following the event and subsequently refused to get out of bed. The resident was sent to the emergency room for evaluation and later admitted to the hospital for pain management, where her pain medication was increased. Upon return to the facility, physician orders reflected an increased frequency for pain medication administration, and the care plan noted the need for pain assessment and medication as ordered. Despite these orders, the facility did not effectively manage the resident's pain according to physician instructions, the care plan, or the resident's preferences, resulting in a decline in her ability to participate in routine activities of daily living.