Failure to Assess, Document, and Manage Pain Following Resident Fall
Penalty
Summary
The facility failed to follow its pain management policy and procedure by not adequately assessing, documenting, or treating a resident's pain following a fall that resulted in a significant injury. The resident, who had a history of dementia, neurocognitive disorder, and a right artificial hip joint, experienced a fall and subsequently showed signs of pain, including vocalizations and physical resistance during care. Despite these indications, there was a lack of consistent pain assessments, documentation of pain complaints, and administration of pain medication as ordered. Multiple staff interviews revealed that the resident expressed pain throughout the night after the fall, particularly when being moved or touched, and staff observed bruising and other signs of injury. However, the medical record did not reflect these complaints or the interventions taken, such as administration of acetaminophen or use of non-pharmacological measures like ice packs. The medication administration record showed no documented administration of pain medication during the relevant period, despite orders for as-needed acetaminophen and documented pain scores. The facility's pain management policy required documentation of pain assessment and monitoring, but this was not followed. The Director of Nursing confirmed that there were no new pain management orders post-fall and that documentation of pain complaints and medication administration was expected. The lack of timely and thorough pain assessment, documentation, and intervention resulted in the resident experiencing unrelieved pain while awaiting further evaluation and treatment for a hip fracture.