F0697

K

Failure to Provide Timely Pain Management and Hospital Transfer After Fracture

Dallas, Texas Survey Completed on 04-14-2025

Penalty

Fine: $53,825

Summary

A deficiency occurred when a resident with a history of multiple sclerosis, lack of coordination, and dependency for transfers sustained a fracture to the left tibia after an incident involving a shower chair. The resident reported pain and an x-ray was ordered, which confirmed the fracture. However, there was a significant delay in notifying the nurse practitioner (NP) of the x-ray results, and the resident was not transferred to the hospital until five days after the injury. During this period, documentation and communication regarding the resident's pain and the abnormal x-ray findings were inconsistent and unclear among nursing staff and the DON.

Pain assessments documented in the medication administration record (MAR) did not consistently reflect the resident's reported pain levels, with most shifts indicating no pain despite the resident's statements of ongoing pain after the fracture. As-needed pain medication was not administered on the day of the injury, and the resident reported that the pain medication provided was not effective in managing her pain prior to hospital transfer. The resident also experienced a second fracture to the right leg under similar circumstances, again reporting pain and delayed transfer to the hospital.

Interviews with staff revealed confusion about the process for notifying the NP and following up on critical results, as well as uncertainty about the appropriate steps to take when pain or injury was identified. The facility's policies required prompt assessment and management of pain, especially in cases of fractures, but these protocols were not followed. The failure to provide timely and appropriate pain management, accurate assessment, and documentation resulted in the resident experiencing unnecessary pain and delayed medical intervention.

Removal Plan

• All residents were immediately assessed for any change in condition from their baseline including pain assessment.
• Any resident who verbalized or showed nonverbal signs of pain was addressed at that time following that resident's physician orders for pain management.
• Either DON, ADON D, ADON E, or LVN CC will round the center and observe each resident every 12 hours looking for indications of pain or change of conditions; these rounds will be documented on the resident 24-hour report.
• The ADM will monitor this process daily.
• The following in-services were immediately initiated by the Chief Nursing Officer: any nurse not present or in-serviced will not be allowed to assume their duties until in-serviced.
• The ADM and HR will ensure these team members are removed from the time clock and PCC access removed; this will be monitored until 100% complete or the team members are terminated.
• Ongoing in-service will be completed by DON, ADON D, and ADON E until all staff, weekend, and PRN are completed.
• Post-test will be completed to evaluate team members' understanding of in-services covered; the passing score will be 80% - 100%.
• Licensed nurses were in-serviced on how to assess residents for signs and symptoms of pain using a pain scale appropriate for them.
• Licensed nurses were in-serviced on how to reassess pain after medication administration for effectiveness and process for if not effective.
• Each resident will have a pain management treatment plan as part of their plan of care.
• The medical director was notified of the immediate jeopardy situation by the DON.
• The Ombudsmen was notified of this Immediate Jeopardy situation by the ADM.
• Interviews were conducted with employees to verify understanding of pain assessment, notification, documentation, and identification of pain indicators.
• Record review of facility in-service titled Following Physician Orders to Address Pain revealed all nursing staff had signed indicating education was completed by all nurses.
• Record review of facility in-service titled Assessing the effectiveness of pain medication given revealed all nursing staff had signed indicating education was completed by all nurses and CNAs.
• Record review of facility in-service titled Comprehensive Pain Management Treatment Plan revealed all nursing staff had signed indicating education was completed by all nurses and CNAs.
• The facility will ensure that all mechanical transfer train-the-trainer sessions, center random skill checks, and instances where transferring is found to be done incorrectly, will be supervised, monitored, and approved by a licensed physical therapist.